In the case of William Mead his parents contacted healthcare professionals on numerous occasions but the professionals did not hear and react appropriately to his parents’ concerns (NHS England, 2016). NHS England has developed the ReACT tool to encourage a collaborative approach between healthcare professionals and parents/carers and to empower parents to speak up. 

• Listen to the talks on Improving Communication with Families on the ReACT – the Respond to Ailing Children Tool (NHS England, 2015) website: www.england.nhs.uk/patientsafety/re-act/education/families/

Reflect on how you communicate and engage with parents and carers. How good are you at listening to families? How could you improve your skills?

Answer: Your reflection might have included some of the following:

• Thoughts on how well you listen to parents and work in partnership with them. Parents or your mentor might have provided you with feedback – what did they say, did they identify any areas that you could improve upon?
• Thoughts on whether you have listened when Mum expressed her concerns about Amelie even though Amelie appeared well and was playful.  How you have acted as an advocate for a child/young person/parent/carer.  Looking at whether your host Trust provides information for parents on empowering them to speak out.
• Your thoughts on parents being able to activate an outreach team – discuss this with your mentor. How would the wider healthcare team react? When I’ve discussed it with colleagues they have felt threatened by it. However, the evidence shows that parents react appropriately and can also feel reassured if they are included in the ‘safety huddle’.
• The role of service users in your curriculum – do you have talks from parents/carers in your university?

• Are there any potential benefits for a child having a fever?

Think about what effect a temperature has on a child's immune system and tissue repair. Does a temperature increase or decrease the rate of pathogen replication?

Answer: Increased efficiency of immune system:

• T 37.5°C–40°C increases metabolic rate. With each 1° increase in body temp get 10 per cent increase in metabolic rate
• Therefore enzyme reactions occur at quicker rate, increases mobilisation of cellular immune system, stimulates lymphocyte transformation
• Motility of polymorphonuclear neutrophils improves and phagocytosis becomes more effective

Accelerated tissue repair:

• Due to increased immune efficiency
• Interferon production influenced

Reduced rate of pathogen replication:

• Shift from glucose metabolism to one of lipolysis and proteolysis reduces the amount of free glucose available in circulation that can be used by invading micro-organisms
• TNF, IL-1 and IL 6 stimulate the release of proteins which are used for energy and tissue repair and bind with cations necessary for bacterial replication
• Breakdown of lysosomes destroys cells that have been infected by invading organisms
• Most bacteria are heat sensitive – increased temp leads to reduced growth rate, mobility. Self-destruction of bacteria increases. Viruses sensitive to heat.

Zahra is 3 years old. Her nursery contacted her mother earlier today as she was irritable and had a fever of 37.8°C per axilla. The nursery had given her a dose of paracetamol and were encouraging her to drink, although she was reluctant to do so.

Her parents collected her from nursery and took her to their local urgent care centre as they were anxious about the temperature as Zahra had previously had a febrile convulsion.

At the urgent care centre she was found to have a temperature of 38.2°C per axilla, heart rate of 142 beats/minute, respiratory rate of 28 breaths per minute and oxygen saturations of 96 per cent. Zahra appeared pale, was sleepy and not smiling at her parents, she was reluctant to drink and had not had a wet nappy since the morning. There is no obvious source of infection.

• Using the traffic light system (NICE, 2013) for identifying risk of serious illness, describe what level of risk is Zahra displaying.

Answer: Amber – intermediate risk

• What actions would you take and why?

Answer: Her parents are anxious due to her previous history of a febrile convulsion and no diagnosis has yet been reached. It would not be appropriate to send her home with a ‘safety net’. Refer to the rapid assessment clinic at the local hospital to be seen by a paediatrician.

Zahra urine should be tested (NICE, 2007).

• Zahra is seen in the rapid assessment clinic at the local hospital and the decision is made to admit her. With reference to the NICE guidelines what further investigations would need to be performed?

Answer: Clean catch urine tested for urinary tract infection, bloods for FBC, C reactive protein and blood cultures. CXR if fever is >39°C and WBC greater than 20x10(9)/litre. As there is no obvious source Zahra should also be assessed for the signs and symptoms of pneumonia e.g. Tachypnoea (RR >40 breaths/minute), crackles in the chest, nasal flaring, chest in-drawing, cyanosis, oxygen saturation ≤95 per cent.

• How often would you record Zahra’s observations (vital signs in hospital)?

Answer: Observations should be recorded in line with Zahra’s clinical condition. An EWS should be used and Zahra’s care escalated in line with it. NICE (2013) advises that a decrease in temperature 1–2 hours after antipyretics have been given should not be used to differentiate between serious and non-serious illness. Children with red and amber features should be reassessed 1–2 hours after antipyretics have been given.

• What anti-pyretic interventions will Zahra require?

Answer: Zahra will require a cool environment but she should not be overcooled as this will cause her to shiver and raise the set point. She will need to be offered frequent cool oral fluids. Paracetamol or Ibuprofen should only be used if Zahra is distressed and should not be used in conjunction unless her distress continues or recurs before the next dose of the chosen medication is due.      

Reference

NICE (2007) Urinary tract infection in under 16s. Diagnosis and management. Available at: www.nice.org.uk/guidance/cg54/chapter/1-recommendations (last accessed 12 February 2018).

Do all children with diarrhoea and vomiting need intravenous fluids? You will remember that we said earlier that most children can be cared for at home. Most children who are not displaying signs of dehydration can be cared for at home – therefore the answer is no, not all children need intravenous fluids. Parents caring for their child at home will need advice on what food and fluids their child can have, infection control measures and when a child can go back to school/nursery.

• What advice regarding food and fluids would you give to a parent caring for their child at home?

Answer: There are lots of myths about what children should or shouldn't have to eat and drink when they have diarrhoea and vomiting. It is essential that our practice is evidence based. Children with diarrhoea lose water and sodium so we need to look at how we can replace this. Glucose and other carbohydrates enhance the intestinal absorption of sodium and water. Therefore, fluid and electrolyte losses are best achieved by giving solutions which contain sodium, potassium and glucose (BNFc, 2015).

You should advise parents that they:

• can continue with breast feeding and other milk feeds
• should encourage fluid intake – give little and often
• should discourage fruit juices and carbonated drinks
• should offer oral rehydration salt (ORS) solution as supplemental feeds if their child is at increased risk of dehydration.  

Infection control measures:

• hand washing – use liquid soap, warm running water, careful drying
• towels – do not share towels of infected children.
• preparation of feeds – correct sterilisation technique

Return to school/nursery:

• the child can usually return to school or nursery 48 hours after their last episode of diarrhoea and vomiting
• the child should not go swimming for two weeks after their last episode of diarrhoea and vomiting

Tobias is seen by the triage nurse in the Emergency Department. He listens to Tobias’s mother’s concerns and assesses Tobias using the age appropriate risk stratification tool for children with suspected sepsis guideline and algorithm (NICE, 2016a) (Table 15.6).

Tobias is found to have a core temperature of 38.6°C, a heart rate of 140 beats per minute, a respiratory rate of 18 per minute, oxygen saturations of 92 per cent in air, capillary refil>3 seconds and systolic blood pressure of 100/75. He is sleeping but responds to his mother’s voice. However, he falls straight back to sleep. He appears pale.

Tobias is graded as having a high risk of sepsis. The nurse fast bleeps the paediatric registrar.

• You are the nurse who has assessed Tobias. Outline the conversation you would have with the registrar using the SBAR tool.

Answer:

Situation:

My name is xxxxx and I am ringing you from the Emergency Department.

I am calling about Tobias X.

I am calling because I am concerned that he has sepsis – he triggers the high-risk criteria using the risk stratification tool.

Background:

Tobias arrived in the ED 15 minutes ago accompanied by his mother.

He is usually fit and healthy. However, for the last 2 days he has been feeling too unwell to go to school. He looks pale and is very lethargic, wanting to sleep all the time. Earlier today he had a temperature but when his Mum felt him just now he felt very cold.

His observations here in the ED are:

• a core temperature of 38.6°C,
• a heart rate of 140 beats per minute,
• a respiratory rate of 18 per minute,
• oxygen saturations of 92 per cent in air,
• capillary refil>3 seconds
• systolic blood pressure of 100/75.
•  he is pale
• AVPU = V. He is sleeping and falls straight back to sleep when awoken. 

Assessment:

I think Tobias is showing signs of sepsis.

I have given him oxygen and taken a blood gas which I am awaiting the results of.  

Recommendation:

I need you to come straight to the ED to see Tobias.

Is there anything I need to do in the meantime?