Sepsis at DFTB17

This talk was recorded live on the second day at DFTB17 in Brisbane. If you missed out in 2017 then why not book your leave for 2018 now. Tickets are on sale for the pre-conference workshops as well as the conference itself at www.dftb18.com.

Sepsis is something that scares us all. The missed or delayed diagnosis of sepsis is a common cause for litigation in paediatric practitioners. But is there a way we can spot every case? Up to 20 percent of children presenting to the paediatic emergency department have a temperature but they do not all have sepsis.  Is there a better way than relying on the gut reaction of the parent or the clinician. Arj Rao introduces us to a framework that might make things a little clearer.

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PARIS in the autumn

As the days get shorter for those of us in the Southern hemisphere it inevitably means that bronchiolitis season is on its way. So far studying bronchiolitis has left us with a big list of things that don’t work – steroids, salbutamol, adrenaline, antibiotics. Chest  x-rays don’t help and NPAs don’t give us any information we can actually use – but what about high flow?

Through the PARIS trial, Donna Franklin and our friends at PREDICT have considered nearly 21,000 infants presenting to 17 different hospitals to try and shed some light on this for us.

Franklin et al, A Randomized Trial of High-Flow Oxygen Therapy in Infants with Bronchiolitis. NEJM. 2018. 378(12):1121-1131

Who did they look at?

Infants <12 months old with a clinical diagnosis of bronchiolitis and a need for supplemental oxygen to keep their SpO2 in the range 92-98% or 94-98% (target sats range varied by hospital as hospitals had different guidelines at the time of the trial). Of the 20,795 children screened, 1638 were randomized. The bulk of exclusions were for disease too mild to warrant treatment or for having an alternative diagnosis, other exclusion criteria all have pretty logical reasons (e.g cyanotic heart disease, craniofacial abnormalities or need for home oxygen). After removing those for whom consent could not be obtained 1472 made it through to analysis.

What did they do?

The intervention group were placed on heated humidified high-flow oxygen at 2L/kg/min via an Optiflow system.* Notably this flow rate is double the 1L/kg/min used by Elizabeth Kepreotes and her team in what, prior to PARIS, had been the largest trial of bronchiolitis in high-flow conducted in Australia (1). The PARIS trial adjusted the FiO2 to achieve sats in the target range, followed by weaning down to 0.21 to use the lowest FiO2 possible to achieve those target sats. Kids whose FiO2 had been at 0.21 for 4 hours were taken off high-flow. I’m laboring the details of this process because I think PARIS is setting a standard as I will explain below.

What were they comparing it with?

Infants in the standard therapy group got plain old wall oxygen through standard nasal cannulae up to a maximum flow rate of 2L/min (note this is NOT weight dependent) again weaned so as little oxygen as possible was being used to keep the sats in the target range.

What did they find?

The primary outcome was treatment failure that resulted in the escalation of care during the hospital admission. Treatment failure was defined by the child meeting any 3 out of 4 clinical criteria (heart rate remained unchanged or increased since admission, resp rate remaining unchanged or increased since admission, needing oxygen at either >2L/min (standard group) or and FiO2 >0.4 (high-flow group) to maintain minimum target sat, scoring high enough on the hospital’s early warning tool (CEWT/between the flags/Victor/etc) to warrant escalation of care. Potentially problematically from the study point of view, but unavoidably in real life, clinicians were also able to escalate care based on any other concern – and many did so. For those in the standard therapy arm “escalation of care” was recommended to, and universally did, mean high-flow. Escalation of care occurred in 12% (87/739) of the high-flow group and 23% (167/733) of the standard therapy group. Via some maths that sounds plausible to me this gave a number needed to treat of 9 to avoid one escalation of care.

Hospitals with an onsite ICU escalated care in more of the patients on high flow (14% vs 7%) and fewer of the patients on low flow (20% vs 28%) than hospitals without an on-site ICU. This makes sense given the practical barriers to escalating beyond high-flow in facilities without a PICU onsite. 34% of infants who had their care escalated had it done on the basis of clinician concern, not the pre-defined physiological parameters and this was more common in the standard therapy group. This perhaps reflects the widespread belief that high-flow is helpful in this situation making it harder for people to hold back. Looking only at the infants who triggered the physiological criteria, escalation was still more common in the standard group than the high-flow group (16% vs 7%) supporting the conclusion that high-flow does indeed reduce the objective need for escalation of care.

Historical factors such as prematurity and previous admission with bronchiolitis made no difference to the findings, nor did positive identification of RSV in the patient’s nasopharynx.

Secondary outcomes showed no differences in duration of hospital stay, duration of ICU stay or duration of oxygen therapy. 12 infants were intubated, giving an intubation rate of just under 1% of the bronchiolitic infants who made the inclusion criteria. Importantly, adverse event rates were both low and equivalent in both groups with one pneumothorax in each group, neither of which needed draining.

The bottom line.

This is the biggest and most robust trial yet done to assess the value of high-flow in bronchiolitis. The primary outcome shows that there is a role for high-flow in the non-ICU management of this disease. Importantly PARIS has shown in a large cohort of children that high-flow, when used within the parameters of the trial protocol, does not lead to an increase in adverse events which in-turn suggests the increased patient:nurse ratios for kids on high-flow that are often mandated by hospital policies may not be necessary (depending on the severity of disease of course). Some caution must be used around the potential for erroneous use of the high-flow circuits themselves and the interpretation of early warning scores in the context of high-flow use.

PARIS was supported with significant nursing education resources potentially reducing errors to a level that were below what could be expected with the standard resourcing of mixed EDs and other environments where high-flow use in children may be infrequent. As with many grey areas in medicine protocols as to how we use high-flow vary by institution with little more than opinion to guide them.

Though neither the intention nor the conclusion of this paper in showing the progress of such a large number of children on high-flow, this trial also provides a basis for more robust decision making around how we use high-flow itself.

We will try and encourage some of the authors of this paper to share their insights with us on DFTB, indeed a few will be speaking at DFTB18 in Melbourne in August.  In the meantime we would love to hear what you think in the comments section below and enjoy our infographic summary.

*Fisher and Paykel who manufacture the Optiflow system have provided financial support to both the DFTB17 and DFTB18 conferences

  1. Kepreotes et al Lancet 2017; 369: 930–39
  2. Franklin et al. BMC Pediatrics (2015) 15:183

 

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On Rudeness

“Hey Tessa, I didn’t realise you were such a genius”.

I was on my way back to ED from my lunch break and the ortho reg was sitting laughing with one of our locum SHOs.

I smiled nervously, “Oh thanks for coming to see the patient”.

“I didn’t realise you were a genius”. He said it again. He was still smiling. It was weird.

“I’m not sure what you mean, but something about this is making me nervous”. I was trying to make a joke of it. But let’s be honest, I’m not a genius, so I had a sense that something wasn’t right.

“You told my patient that they could eat and drink. They need an operation and now they aren’t fasted. Thanks for that, genius!”

I have since thought of a gazillion things I could have said. Like, “I didn’t tell them they could eat and drink!” or “Hang on, there’s no need to be rude” or “You’re setting a really bad example to this locum SHO about how to be courteous to your fellow colleagues” or “It doesn’t cost to be kind!”.

Actually, he walked away before I could say anything else. I’ve spent the weeks since pondering over it endlessly. That’s pathetic, right?

Yes, we work in busy and stressful environment. We have all snapped from time to time, it doesn’t mean that you’re a bad person, or a terrible doctor. But at the same time, we need to let people know that it’s not ok to be spoken to like that. We need to set a good example for our juniors, to help change the culture, and also to preserve our own self-respect. My reaction was disappointing (at least to me anyway). How should I have done it better?

 

The DFTB team asked a few docs whose opinions we value greatly – how should you respond when someone at work is rude to you?

Here are the collated answers and themes from: Dara Kass (DK); Vic Brazil (VB); Simon Judkins (SJ); Damian Roland (DR); and Natalie May (NM).

 

Most people aren’t actually horrible people who want to see you suffer…

In the hectic nature of acute medical practice, clinicians can become tired,  hungry or the deadly combination of both. This can lead to frayed tensions and communication challenges. Sadly it’s often the case that rudeness is a part of normal process, rather than an unacceptable professional dynamic. DR

And sometimes, it’s possible it wasn’t meant in the way it came across…

There are many perceptual challenges around ‘rudeness’ as there is no strict definition of what it actually is. You know it when you see or hear it, but can’t necessarily always describe it. I personally believe that many people honestly don’t believe they are being rude, or if that is being too charitable, that the impact of the tone of their voice or choice of language isn’t considered. DR

We all have plenty of everyday reasons to feel some anger at work…

Usually the person is rude because they are frustrated, either with the system, the medical issue or their own lives. Rarely, the patient’s rudeness is just a personality disorder, and then I just try to interact with them as little as possible while delivering excellent care. 🙂 DK

As a senior, if this rude behaviour happens, we jump on it early, but it is also very important to listen to both sides of the story; there is often a tale of grief/stress on the other side which we need to also recognise and support. I don’t think there are many true asses out there, but many people who feel unsupported and vulnerable. SJ

Try to look on it in the most positive light and give them the benefit of the doubt…

Follow Jenny Rudolph’s #WTF2WTF … take a breath and think why? Trying to be generous in possible motivations might help. VB

 

But if it’s clearly rude, then we really need a strategy on how to deal with this. The key is to reframe is – move away from it being about the words they used or their tone when they spoke to you and try to find some common ground…

I am rarely responsible for the cause of their frustration but try to validate their experience and see what I can do do diffuse the issue. DK

Try to keep the focus on the patient i.e. both parties needs to keep the focus on the patient and not get lost in a personal dispute…

Frame all conversations with colleagues in the context of the patient’s needs – and believe first and always that your colleagues have the patient’s best interests at the centre of their intentions. NM

It’s also important to acknowledge the positives. Being kind and professional make for a happier work environment for all…

Emphasise how important good behaviour is e.g. ‘we really want to get along with our work colleagues here’. VB

And an important point to consider is that being right and being rude are two separate things. There will be times when something doesn’t go smoothly, and it might be your fault. The person being rude may be right i.e. you did indeed do something wrong, but that doesn’t give them the all-clear to be rude…

Separate the issue from the rudeness ie the person being rude might actually be ‘right’, but the conversation should clarify that the issues are separate and being right doesn’t justify the rudeness. VB

Debate around patient care is vital, in fact it is an essential element of patient safety. However, there is no reason the tone of that debate should cause discomfort to those having it. DR

 

There will be times, where you need to just confront the problem and ‘call it’. Choose your language carefully…

Use words like ‘disappointed’, ‘surprised’, and ‘what a shame’ VB

I tend to call things out, “I’m really sorry, but I don’t think I deserve to be spoken to like that. I appreciate your different point of view but how can we resolve this in the best interests of the patient.” Written down, playing the ‘patient card’ sounds glib, but in practice directing attention towards the one thing you have in common with the other person tends to clarify thinking. DR

When confronted with rudeness, pause – count to five in silence (it might need to be ten!) – then prompt reflection (the sentence I’m trying to use is “you might like to think about how that came across”). NM

It’s tough when your not expecting it..my responses vary, but usually involves highlighting the unprofessional behaviour, asking them to reflect and continue the conversation when they are ready…like I do with my teenage boys! SJ

 

‘Calling it’ doesn’t mean start an argument with them. Otherwise that defeats the purpose of your response…

Avoid interrupting or talking over people who have already escalated their behaviour – this fire will usually burn out on its own and is best countered with coolness, not more fire! NM

If rudeness/hostility continues, use graded assertiveness or giraffe feedback to shift focus to immediate needs and patient safety. Rudeness is potentially a patient safety issue. NM

 

It might not be appropriate to respond at the time for a multitude of reasons, and that’s ok…

There is nothing wrong with having the conversation later (and in many respects it might be better)….keeping the ‘marriage counselling’ lingo focused on behaviour and impact -“when you did x, I felt like y” VB

 

You don’t need to perseverate on your own about this, speak to your colleagues. They’ll all have been in a similar situation.

Consider cold debrief after such incidents with a trusted colleague and appropriate escalation as warranted by the incident (this will vary). NM

There is also nothing weak about others having these conversations for us, at least to open it up…. “My intern is pretty upset about a discussion you guys had. I truly don’t know what happened , but the impact was pretty bad . I thought you’d like to know as I doubt that was intended …..” VB

The other approach we use with our DITs is to suggest that “ it seems that we aren’t going to agree on this issue, so I think we should end this conversation. I’ll ask my Boss to call your Consultant and they can discuss a solution “. SJ

 

These lessons shouldn’t be just for one someone speaks rudely to you. It’s our job to look after our colleagues too…

Calling out rudeness when witnessed is also vital. As a senior clinician while it is easy to pretend you haven’t overheard conversations, letting things go because they don’t directly affect you propagates a culture in which the status quo remains acceptable. DR

 

Sometimes, your response will make the person realise they were rude. And they might even apologise. Allow them to do so!

Allow space for insight and apology – if the person being rude apologises, accept the apology and move on. Harbouring negativity helps no-one. NM

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