Title: Dynamic Electronic Tracking and Escalation to reduce Critical Care Transfers (The DETECT study)
Funder: Department of Health and Social Care

Abstract: Participants: Paediatric tertiary hospital in-patients (240 beds). Methods/design: Stepped-wedge prospective study exploring the impact of pro-active patient monitoring on SDE, sepsis identification and emergency transfer to Critical Care. Intervention: VitalPAC Paediatric, with underpinning age-specific PEWS risk model, PS6 clinical prompt and in-built process control, Comparison: Retrospective with matched time-frame preceding year, standard in-patient monitoring (Meditech 6 electronic patient record) Primary outcomes: Emergency transfers to Critical Care (PICU/HDU): number, total bed days, severity of illness (using PRISM III), length of stay. Sepsis identification and response. Interventions (days): mechanical ventilation, non-invasive ventilation, inotropes, dialysis. Secondary outcomes: SDE: Cardiac arrests, respiratory arrests, activation of resuscitation team. Mortality (all cause). Critical care activity: Total PICU/HDU admissions, bed days, severity of illness, length of stay. Internal/external refused emergency admissions. Planned major surgery cancellations. Hospital activity: Total (ward) admissions, total bed days/month, length of stay. WP1. Site technical preparation for implementation of VitalPAC Paediatric Testing of Wi-Fi signal, interface with Meditech 6 and pathology results (PS6 clinical prompt), IT standard operating procedures (SOPs), event log. Bench/clinical testing of upgraded VitalPAC paediatric prototype. TLC/RK/GS/ IMT staff. Deliverable: Phased whole hospital implementation of VitalPAC Paediatric. Milestone: Fully functional VitalPAC Paediatric technology on in-patient wards. WP 2: Achieve compliance with pro-active monitoring of in-patients. Weekly ward feedback: timeliness/completeness of monitoring, escalation at PEWS >/=6 and response. PS6 clinical prompt compliance, incidence of SDEs, emergency transfers to Critical Care, cancelled major elective surgery. GS/RK/EC/BC/Cons Paed/research nurses. Deliverable: Process control metrics suitable for children. Milestone: Standardisation patient monitoring, improved timeliness of assessments. WP 3: Quantitative evaluation of clinical utility of VitalPAC Paediatric. Modelling of data to improve the evidence-base and clinical utility. Statistical analysis of the clinical utility of VitalPAC Paediatric in predicting serious illness; sensitivity, specificity, positive/negative predictive values. Modelling of data to determine evidence-based thresholds for vital signs and weighting of components of the PEWS risk model to improve performance. Investigate the feasibility of using stochastic control methods to track the condition of patients over-time. SL/GS/EC/ Cons Paed. Deliverable: Evidence-based age-specific PEWS risk model. Milestone: An age-specific PEWS risk model calibrated for optimal performance. WP4: Evaluation of PS6 clinical prompt Identification of children with sepsis, Compliance with the PS6 management algorithm. Emergency transfers to Critical Care with sepsis. Measure effectiveness/clinical utility of VitalPAC Paediatric Sepsis prompt to identify at-risk patients. EC/GS/SL. Deliverable: Accurate clinical and laboratory prompt to identify sepsis. Milestones: Incorporation of PS6 clinical prompt. WP 5: HE analysis of cost-effectiveness of implementing VitalPAC Paediatric Identify hospital activity data and identify and cost SDEs and emergency transfers to Critical Care, calculate implementation costs: BH/EC/GS/SL/Informatics/research nurses. Deliverable: Report of HE Analysis of VitalPAC Paediatric in a tertiary hospital. Milestones: Completion of HE analysis. WP 6:Development of a qualitative evidence base to inform and support development VitalPAC Paediatric based on the experiences of patients, parents and clinicians. BC/JP/EC/ SL/GS. Deliverable: In-depth qualitative evidence of the real-life use of VitalPAC Paediatric across different settings, in different situations and from the different perspectives. Milestones: Completion of data collection and analysis and reports on reports on the clinician user-acceptability and patient/family experience. WP 7: Project management Research governance, ethics approvals, SMG/SSG meetings, PPI involvement, data analysis, dissemination. MP/EC/BC/JP/BH/RK/SL/GS. Deliverables: Effective and collaborative project management and delivery between NHS/ commercial/university partners. Milestones: All milestones achieved on time and on budget. WP 8: Evidence for CE certification, NHS and broader commercialisation Data for technical and safety file for CE certification, marketing strategy, stakeholder engagement, host site visits to showcase project, dissemination.RK/ TLC/System C/study project team. Deliverable: Engagement of stakeholders/early adopters. Milestones: Registration of CE certification. Successful launch and dissemination events involving stakeholders.

Lay abstract: Missed clinical deterioration is a huge problem in the NHS, leading to emergency transfer to critical care, and at worst, death. Children who require emergency admissions to critical care are sicker, need more intensive treatment and have a longer stay than planned admissions. This study will evaluate whether using an electronic surveillance system incorporating a paediatric early warning score (PEWS), can identify signs of deterioration earlier, so that urgent treatment can be given, and if this prevents emergency admission to critical care. VitalPAC is an electronic hand held device which records vital signs to help detect deterioration. VitalPAC has been shown to improve serious illness recognition and reduce deaths in adults. There is potential for similar benefits for children. However, the device used in adults is unsuitable for children because: Signs of serious illness in children differ from those in adults. Vital signs (heart rate, breathing and blood pressure) change markedly throughout childhood and into adulthood. Children become seriously ill quicker than adults, particularly when they have severe infections (sepsis). Consequently, there is greater urgency to act quickly to prevent emergency transfer to critical care. The bedside nurse directly inputs vital signs into a VitalPAC Paediatric device. It automatically charts these and calculates the PEWS, eliminating errors. The vital signs are immediately uploaded to the network so they are instantly visible to the doctors and nurses. Higher PEWS scores indicate deterioration and triggers urgent action. Senior nurses and doctors also carrying a device are alerted, without the nurse undertaking the observations leaving the patient s bedside. They can respond quickly to provide life-saving therapy. We will assess VitalPAC Paediatric in a children s hospital to determine its capability of detecting deterioration early, reducing emergency admissions to Critical Care and whether it provides value for money for the NHS.

Research activity codes: 7.3 MANAGEMENT AND DECISION MAKING
Health categories: INFECTION;GENERIC HEALTH RELEVANCE;INFLAMMATORY AND IMMUNE SYSTEM