Working together for the sick or injured child: the Tanner Report

'It takes a village to raise a child.' (African proverb) It may take a village to raise a child, but what does it take to salvage a sick one? Maybe the combined resources of the NHS. This, at least, was approximately the conclusion reached by the working party which produced 'The acutely or critically sick or injured child in the District General Hospital: A team response'[1]. The idea for the document arose out of discussions between the Royal College of Anaesthetists and Professor Stuart Tanner, then National Clinical Director for Children. The provision of anaesthesia for children has undergone a pendular swing in the last 15 years. Before the publication of the National Confidential Enquiry into Perioperative Deaths 1989 (NCEPOD) report [2] into deaths in children in the peri-operative period, virtually all anaesthetists anaesthetised children of any age who presented within their professional ambit. The publication of this report, followed by a spate of others [3–5], lent impetus to a growing view that young children required specialist anaesthetic care. Whereas in 1975, 70% of children were anaesthetised in district general hospitals by non-specialist anaesthetists [6], by 2003–4 this proportion had fallen to 61%[7]. Because anaesthesia for children had been concentrated in the hands of a smaller number of anaesthetists in a smaller number of centres, many who had previously regarded themselves as 'competent' no longer 'did' children. This, of course, becomes a self-fulfilling prophecy. Perceived incompetence may become real as a result of lack of practice and loss of confidence. Despite this, many (or most) of the hospitals in which these anaesthetists worked maintained open access accident and emergency (A&E) departments, where children were admitted. There are not many District General Hospitals (DGHs) with a large enough number of suitably qualified children's anaesthetists to run a separate rota; emergency services out of hours were thus being provided by anaesthetists no longer deemed 'competent', by virtue of continuing experience, to provide anaesthesia for children during the day. As recently as September 2006, the Healthcare Commission published a report [8] in which it highlighted that there is a lack of training for surgical and anaesthetic staff working on serious paediatric emergencies. The Commission identified this as a serious issue because 20–25% of the child population needs emergency care every year. The problem was recognised by the Royal College of Anaesthetists in 2002, with the publication of 'Paediatric anaesthesia and critical care emergency services in hospitals'[9]. This detailed the minimum skills (intubation, ventilation, the establishment of invasive monitoring and possibly transfer) required by on-call anaesthesia and critical care teams in hospitals which received unrestricted paediatric emergencies. It acknowledged that each skill had to be possessed by at least one member of the duty team, and that appropriate equipment and trained assistance must be available. It set standards, but did not elaborate on how to achieve them. This led to a considerable amount of anxiety for individual anaesthetists and departments of anaesthesia and critical care. It was to address this anxiety that Prof. Tanner agreed to set up a working party of anaesthetists and paediatricians to consider practical solutions to the problem. As so often happens, it rapidly became apparent that anaesthetists and paediatricians were not enough, and the working party 'growed like Topsy'[10]. The final group included specialists in emergency medicine, surgeons, nurses, the ambulance service and a family representative. Even then, the GPs protested, probably correctly, at being left out. One of the interesting features of the early meetings was the realisation that anaesthetists were not the only ones worried about deskilling. Many consultant paediatricians have little daily contact with acute paediatrics, many A&E departments admit few acutely ill children, and ambulance personnel may have little paediatric training and experience. The acutely critically ill child, for each individual working in the DGH, is a relative rarity. From this realisation rose the central theme of the document – that it was the skills and competencies of the team, rather than the parent discipline of the individual members, which mattered. Six generic skills are expected of all personnel involved with the care of the critically ill child (para 2): to recognise the critically ill child; to initiate appropriate medical treatment; to act within a team; to maintain and enhance skills; to be aware of issues of safeguarding children; effective communication with children and carers. Needless to say, the level of theoretical and technical expertise expected of different members of the team varies with their specialty, their training and their seniority. Of specific relevance to anaesthetists is the observation that (para 6.6.1) '– it is better for any consultant anaesthetist to be managing a sick child's airway than for anyone else to attempt to do so. The anaesthetist's skills are key to stabilisation, particularly in the scenario of deterioration of an acutely sick child'. There is a comforting corollary to this. Too often, the sick child is left in the care of the anaesthetist, who should have resuscitation and stabilisation skills, but cannot be expected to be expert in the diagnosis and management of childhood diseases. The document states (para 6.6.2) that consultants in paediatrics will be responsible and therefore in charge of children, and they must play more than a nominal role. The child's journey begins with the realisation that he/she is critically ill. This is often (but not always) outside a hospital and the document makes a number of practical suggestions for systematic preplanning which is vital to the safety of the individual child. An ambulance crew will normally take a patient to the nearest hospital. However, there is little point in taking a child to a hospital with no paediatric expertise and no suitable resuscitation equipment. It is clearly more appropriate to travel to a hospital with paediatric facilities, even if that entails a longer journey – provided that that journey is not so long that the child will come to harm in the ambulance. This decision requires the ambulance crew to make a clinical judgement and also to have knowledge of the facilities available. Each clinical community should have a plan encompassing 'drive-by' policies developed within a network of paediatric emergency care (paras 4.8–4.10). The receiving hospital must have a clinical team able to stabilise the condition of the child. This team comprises, as a minimum (para 6.4), a paediatrician, or paediatric emergency medicine consultant, an anaesthetist or intensivist (who will usually, but not necessarily, be an anaesthetist) and a nurse, working in concert with A&E or ward staff. Other specialist staff may be required, depending on individual circumstances. The document emphasises (para 6.5) that 'following the initial stages of resuscitation of a critically ill/collapsed child, stabilisation and further management should not be left solely to the anaesthetist'. The sickest children will require transfer from the DGH to a tertiary centre. Most such transfers will be undertaken by the retrieval team for the nearest available paediatric intensive care unit (PICU). However, and paradoxically, the very gravest of emergencies, such as severe head injury or intracranial bleeding, will often have to be transferred by personnel from the DGH, because the transfer is time critical and the retrieval team is not available within a safe time frame. Such transfers (para 8) must be managed in close liaison with the tertiary centre, and plans must be in place in advance of the situation arising. Escorting personnel (usually a doctor and a nurse) should have appropriate training and experience. Pre-packed and checked equipment and drugs must be available. Where there is time for a retrieval team to come out from the tertiary centre, the situation is generally easier. There should, of course, be close liaison and telephone advice as soon as the need becomes apparent. In some circumstances, the clinical members of the retrieval team may travel to the DGH in advance of the ambulance, to assist with the rapid stabilisation of the child (para 8.9). In any event, any hospital receiving children must be able to initiate Level 2 intensive care and stabilise while awaiting retrieval [11]. The complex management of critically ill children can best be organised within networks (para 9.1), and indeed, this is what has already happened in many areas. The lynchpin in the networks, however they are organised, is the specialist or tertiary centre, and more specifically, the PICU within that centre. These provide an immediate source of advice and support while stabilisation is carried out at the DGH. The working group felt strongly that the PICU in this situation has a responsibility to the DGHs in the network (para 9.7). If the patient is accepted by the PICU, and the retrieval team goes out, that responsibility is explicit. However, where the PICU has no available bed (as is often the case), it is an abrogation of responsibility simply to refuse an admission. The network tertiary centre should offer clinical advice, and take responsibility for helping to locate a suitable bed. This will remove the administrative burden from the DGH team, who are probably stretched to the limits of their resources and their competence in caring for the child. The admission of an acutely critically ill child, in a hospital where this is a relative rarity, is stressful for all of the professionals concerned. It is, it goes without saying, infinitely more stressful and frightening for the family. The document includes a chapter (para 12) on 'The needs of families' which gives sound practical advice on how to help families through this most difficult of experiences. The document brings together current thinking on the standards which are required of hospitals in dealing with an acutely ill child. It also provides recommendations and practical advice on how to achieve these standards, monitor and audit them, and maintain them. For me, however, its main value lies in the light it focuses on the duties and responsibilities of those who care for these children, directly or indirectly. There is an individual obligation on the professional to keep skills and competencies up to date and practised. This can be achieved by attendance at courses, appropriate continuing experience, the use of simulators or practical refresher training. The onus on anaesthetists who do no routine children's anaesthesia but participate in the on-call rota is clear. There is a team obligation to practise together. This is best achieved by the use of real-time, real-environment scenarios to provide practise and to test the system. There is an organisational obligation to provide the equipment and facilities required for resuscitation and stabilisation. There is also an obligation to provide the time and resources needed for training and practise. There is a professional obligation on a doctor to make the care of the patient his first concern [12]. This is expressed explicitly in the document (Recommendation 7 iv): 'Where an anaesthetist is required to act beyond his or her practised competencies, it is his duty to make the care of the patient his first concern.' It is made quite clear that it is not acceptable to try to opt out. This recommendation continues with the obligation of the employer: '– and it is his employing trust's duty to support him.' Elsewhere (6.6.1) this duty is even more clearly spelt out: '– his employers have a duty to support him if the outcome is imperfect'(my italics). I am not aware of any incident in which an anaesthetist has been criticised, disciplined or penalised for coming to the aid of a sick child 'outside the limits of his or her practised competence'. Nevertheless, the fear is very real [13], and it is reassuring to have so clear a statement of the employer's responsibilities. There is an obligation on the consultant paediatrician to maintain personal involvement in, and responsibility for, the care of the child. This will be a welcome proviso to many anaesthetists who have been left isolated, anxiously awaiting the arrival of the retrieval team. There is a stated obligation on the tertiary centre and its PICU to provide timely advice, support and practical help in locating a suitable bed. The working party arose out of the anxieties of anaesthetists in providing emergency specialist care to children, when many felt that recent developments had led to the loss of the necessary skills. It appears that anxieties about these skills, in this particularly vulnerable group of patients, are not confined to anaesthetists alone. The solution, as propounded in this document, is the development of strong multidisciplinary teams and carefully co-ordinated networks of care. What is not acceptable, for individuals or for organisations, is to evade the issue. We began with a piece of African wisdom We might end with a Talmudic summing up: 'It is not up to you to complete the work (of healing the world), but neither are you free to refrain from it.' (Pirkei Avot: Ethics of the Fathers)