Don't just stand there - #ReACT! ReACT - the Respond to Ailing Children Tool

Author: Dr. Damian Roland
Consultant and Honorary Senior Lecturer in Paediatric Emergency Medicine
Leicester Hospitals

Children get ill. It is a predictable and universal event. The snotty nose, the frustrating cough, the clinginess of a high fever are all part and parcel of the challenge of parenthood. In the vast majority of cases, the unwell child comes nowhere near a health care professional. The self limiting illness resolving in a couple of days with a smiling toddler returned to their normal state of persistent mischief.

Unfortunately, there remain a variety of medical conditions, surgical complaints, and injuries that have devastating consequences for children and their families. The current challenge is that, for a variety of reasons, demand for health care services - whether at a community or hospital level - is increasing. Any health care professional who deals with children faces an ongoing observational puzzle of selecting the well from the unwell, the stable from the deteriorating, the sleepy from the exhausted. Parents and carers are generally their child's greatest advocate so in the vast majority of cases appreciate that something isn't right. But serious case reviews - both in and out of the hospital setting - continue to tell us critical conditions are not recognised by health care professionals for what they are, and children and young people are only partially treated, or sometimes not at all.

NHS England have brought together an evolving repository of resources to aid health care professionals and parents recognise serious illness in children. It is called #ReACT - the Respond to Ailing Children Tool and is free to access for anyone (you don't even need a password!)

The principle behind #ReACT is the utilization of four domains. These are based on consensus opinion and represent an easy to understand entry into the website to maximize relevant learning for individuals or organisations using it.

#ReACT The Respond to Ailing Children Tool:

The component parts are:

Parent/Carer Engagement:
Often the concerns of parents are not heeded or parents are not equipped or confident to raise their fears.

This section contains videos on Families as Partners in Achieving Safer Care and the effect of criticism on parents of sick children.

Health Care Professionals Training:
Many health care professionals have not had primary paediatric training and see children as only a small part of their workload or intermittently. The low incidence of serious illness means it is possible to become de-skilled in many aspects of recognition and reaction.

This section contains advice on spotting sick children - both from a clinician's individual perspective and from an organisation's strategic educational perspective (Chair of the Paediatric International Patient Safety and Quality Community (PIPSQC), Dr. Peter Lachman, helped deliver this video!). Deterioration in children with complex conditions is also covered along with a video specifically related to paediatric sepsis. Finally, some of the rarer causes of deterioration are discussed - a must view for anyone working in emergency and acute care.

Not recognising physiological change:
It is well recognised that physiological parameters often deviate from normal in the hours before collapse.

This section contains an introduction to the principle of PEWS and also a fascinating video on the importance of design factors - an often overlooked principle when considering early warning systems.

Systems Failure:
A variety of Human Factor and Implementation issues often combine to create a paradigm where mistakes are missed or responses are too slow.

The Human Factors influence on missing deterioration in children is covered.

As well as the ReACT talks, there are a variety of document and website links. This will be iterative so please contact me if you have suggestions for more resources.

Over time, the visual look of the website will improve, but for the moment we hope the resources are beneficial to you and your colleagues.

Introduction Video:
Scores and Systems: What is a PEWS introduction video

All the best,

Dr. Damian Roland


Related Links:

1. ACSQHC - Example Recognition and Response Systems Resources from Australian Healthcare Organisations
2. ACSQHC - Observation Charts for Paediatric and Maternity Settings (Australia)
3. Ambient Clinical Analytics - Sepsis Sniffer
4. APSF - Monitoring for Opioid-Induced Ventilatory Impairment (OIVI)
5. BedsidePEWS
6. Between the Flags (BtF) (program to improve response to clinical deterioration)
7. Birmingham Children's Hospital NHS Trust: Continuous remote monitoring of ill children
8. Boston Children's Hospital and Etiometry Bring T3 Patient-monitoring Technology to Market
9. Children's Hospitals' Solutions for Patient Safety (SPS) - "Be Part of the Safety Team for your Child"
10. Children's Hospitals' Solutions for Patient Safety (SPS) - Hospital Resources
11. Cincinnati Children's - Emergency Codes Outside the Intensive Care Unit (ICU) - Operational Definition
12. Cincinnati Children's - Implementing Patient- and Family-Centered Rounds
13. Current Evidence and Implementation of Paediatric Early Warning Scores PEWS
14. Digital Health - Signs of Life (VitalPAC and Nervecentre eObservations)
15. Global Sepsis Alliance
16. Keeping Kids Safe During Critical Illness and Resuscitation
17. Making it Safer Together (MiST) Paediatric Patient Safety Collaborative UK
18. National Pediatric Readiness Project - Toolkit (ensuring emergency care for all children)
19. Nervecentre - Electronic Observations - Electronic capture, calculations of EWS, and automated cascading escalations
20. Nervecentre - Solutions (eObservations; eHandover; Clinical Assessments; Communications)
21. NHS - Children's and Young People's Services Safety Thermometer (Deterioration; Extravasation; Pain; Skin Integrity)
22. NHS - Hospital at Night (HaN)
23. NHS - Integrated Digital Care Technology Fund
24. NHS - Patient Safety Briefing Film
25. NHS England - Children and Young People's Patient Safety Expert Group
26. NHS England - Electronic PEWS
27. NHS England - Exploring a National Paediatric Early Warning System (PEWS)
28. NHS England - PEWS Resources
29. North Shore LIJ saves thousands of lives with sepsis initiative
30. PaSQ - Paediatric Early Warning Scores (PEWS)
31. ReACT - the Respond to Ailing Children Tool
32. S.A.F.E - Improving Child Health Outcomes through Situation Awareness
33. Situation Awareness for Everyone (S.A.F.E) Programme
34. Spotting the Sick Child
35. UK Sepsis Trust - Acute Paediatric Toolkit: Paediatric Sepsis 6
36. VitalPAC (clinical system for analysing patients' vital signs)
37. WFPICCS - Sepsis Initiative
38. WIHI - A Partnership to Reduce Deaths from Sepsis
39. WIHI - Situational Awareness and Patient Safety

Related Publications:

1. AHRQ - Guide to Patient and Family Engagement in Hospital Safety and Quality
2. Bringing I-PASS to the Bedside: A Communication Bundle to Improve Patient Safety and Experience
3. But I told you she was ill! The role of families in preventing avoidable harm in children
4. Daily Check in for Safety
5. DETECT Junior Manual: detecting deterioration, evaluation, treatment, escalation, and communicating in teams; the paediatric approach
6. Developing and evaluating the success of a family activated medical emergency team: a quality improvement report
7. Developing person-centred analysis of harm in a paediatric hospital: a quality improvement report
8. Developing the surveillance algorithm for detection of failure to recognize and treat severe sepsis
9. Finding patients before they crash: the next major opportunity to improve patient safety
10. Health care huddles: Managing complexity to achieve high reliability
11. Huddling for high reliability and situation awareness
12. Impact of introducing an electronic physiological surveillance system on hospital mortality
13. Improving situation awareness to reduce unrecognized clinical deterioration and serious safety events
14. In situ simulation: detection of safety threats and teamwork training in a high risk emergency department
15. Innovative teaching in situational awareness
16. Integrated Digital Care Record - Success Story: Safer Hospitals, Safer Wards Technology Fund
17. Monash Children's Hospital Paediatric Emergency Medication Handbook
18. Multicenter Collaborative Approach to Reducing Pediatric Codes Outside the ICU
19. Optimizing patient safety for paediatric patients in 5 Dutch general hospitals
20. Roadmap for Patient and Family Engagement in Healthcare Practice and Research
21. Situation awareness: a new model for predicting and preventing patient deterioration
22. Step Toward High Reliability: Implementation of a Daily Safety Brief in a Children's Hospital