Background to Bristol Royal Hospital for Children (BRHC)
The Clinical services of the BRHC sits within the Division of Women’s and Children’s Services, which is one of five divisions of the University Hospitals Bristol NHS Foundation Trust/UH Bristol. The Women’s and Children’s Division is committed to the provision of comprehensive general paediatric care for the children of Bristol and specialist services for purchaser authorities throughout the South Western region and beyond. The Directorate’s philosophy accords with the following principles:-
a. Optimal secondary care for children depends on the effective integration of services between hospital, the community and home, and on close liaison with general practice and primary care.
b. Children are best managed by professionals who are qualified to care for children and by managers who are dedicated to their welfare.
Administrative and managerial structures have been designed to reflect these objectives. Hence, the Division incorporates the following Specialty Directorates:
Acute Medical Paediatrics
Acute Surgical Paediatrics
Paediatric Cardiology/Cardiac Surgery
Neurosurgery, Plastics and Burns
Oncology/Bone Marrow Transplantation
Neonatology
Community Child Health
Paediatric Intensive Care
BRHC is the second oldest Children’s Hospital in the country, founded in 1866. The Children’s Hospital moved to a new purpose built hospital in April 2001. There are more than 120 in-patient beds with an annual occupancy rate of 80%-90%. In April 2007 the Woodlands Unit (general paediatrics), previously housed at Southmead Hospital amalgamated and occupies a new ward area at BRHC.
Directorate:
Clinical Director for Children’s Services - Mr M Gargan
Lead Doctor for Children’s Services - Dr Gail Lawes
Divisional Manager - Ian Barrington
The Department of Paediatric Anaesthesia
Consultant Cardiac Anaesthetists:
Dr Richard Beringer
Dr Alastair Keith
Dr Peter Murphy
Dr Tim Murphy
Dr Steve Sale
Consultant General Anaesthetists:
Dr Nick Boyd
Dr Anthony Bradley
Dr Natasha Clark
Dr Deborah Duce
Dr Hannah Gill Dr Beverly Guard
Dr Gail Lawes Dr Judith Nolan
Dr Annabel Pearson
Dr Rachel Pettifer
Dr Amelia Pickard
Dr Ari Sampath
Dr Philippa Seal
Dr Philip Segar
Dr Peter Stoddart
Dr Maria Tosca Dr Adrian Upex
Dr Caroline Wilson
Acute pain service:
Sarah Parry
Helen Garsed
Rebecca Clark
Ashleigh Nicholls
A chronic pain service is provided by a multidisciplinary team that includes an anaesthetist/chronic pain specialist.
Advanced Training Post
The Advanced training post in Paediatric Anaesthesia & Intensive Care is a full-time post for six months, though it has been offered as a job-share for 12 months to suitable candidates.
At any one time there are 3 advanced trainees (two from the Bristol School and one from the Peninsula School of Anaesthesia) who are on the same rota as the intermediate and higher trainees from the Bristol School during their 3 months of
general paediatric anaesthesia. The other three months of their six month attachment is spread between PICU, WATCh transport service and paediatric cardiac theatres.
Intermediate trainees from the Bristol School of Anaesthesia complete a three month module at the Children’s Hospital and higher trainees complete a further one or two months in general paediatric anaesthesia.
The advanced trainees are on a 1 in 8 shift with prospective cover during their time on the general paediatric anaesthetic rota.
The general anaesthesia service is consultant led, with the consultant anaesthetist present for neonatal, infant and complex cases. There are daily urgent/emergency and trauma lists and an acute pain round, in addition to the elective paediatric surgical cases in general, urology, orthopaedic, ENT, dental, and oncology specialities. Anaesthesia is also provided for cardiac catheterisation.
There are weekly early morning tutorials and a Friday morning departmental meeting. There are opportunities and an expectation for the fellows to take part in teaching, or an audit or research project during their six months at BRHC.
Royal College Learning Outcomes for General Anaesthesia
For a DGH anaesthetist with a regular commitment to children’s anaesthesia:
Provides safe perioperative anaesthetic care for a wide variety of paediatric procedures performed in the DGH environment independently.
For the Paediatric specialist in a tertiary centre, additionally:
Provides safe perioperative anaesthetic care for a wide variety of complex paediatric (including neonates) surgery and other procedures independently.
Is capable of leading the delivery of care in this area of anaesthetic practice, to the benefit of both patients and the organisation.
Level 3 special interest area Key Capabilities:
For those intending to practice and potentially lead paediatric anaesthesia in a non-tertiary setting
A Provides safe anaesthesia in both the emergency and elective setting utilising techniques to reduce anxiety in all ages including premature babies
B Delivers safe perioperative care to all paediatric patients requiring surgery in a district general setting, including those with complex co-existing disease
C Can gain arterial, intraosseous, peripheral and central vascular access in children and babies
D Uses a wide range of analgesic strategies perioperatively including simple regional techniques for surgeries routinely performed in a district general hospital setting
E Manages massive transfusion in children.
F Explains NHS policy for the provision of paediatric services
For those intending to practice in a tertiary paediatric setting (in addition to above)
G Delivers safe perioperative care to all paediatric patients requiring surgery in tertiary paediatric setting including those with complex co-existing disease
H Uses a wide range of analgesic strategies perioperatively for complex paediatric patients requiring major surgery.
Illustrations
The illustrations are examples of evidence that can be used to show achievement of key capabilities in a particular learning outcome.
It is not intended that they are all completed but they are examples of what can be presented as evidence. A single piece of evidence can be used for a number of different capabilities across various domains and are not necessarily exclusive to the stage of training listed.
This is not exhaustive and other evidence may be used if thought appropriate by the trainer.
Experience of and WBAs for cases in special interest area
Courses: National and International meetings relevant to special interest area, leadership, management
Abstract presented at meeting relevant to special interest area
Practical procedures relevant to special interest area (at least supervision level of 3)
Development of policies and guidelines relevant to specialist interest area
Satisfactory MSF
Satisfactory consultant feedback
The Paediatric Intensive Care Unit
The Paediatric Intensive Care Unit (PICU) at Bristol Children’s Hospital has 18 beds with funding currently for 17 staffed beds. The Unit is the only tertiary intensive care unit for children serving the South West of England. PICU provides general paediatric intensive care in addition to providing care to sub-specialities including cardiothoracic, neurosurgery, plastics, burns, renal, orthopaedic, general surgery and oncology/post bone marrow transplantation.
Approximately 400 cardiac cases per year are undertaken at the Children’s Hospital. There are twice daily joint rounds between members of the intensive care staff and paediatric cardiologists and cardiac surgeons. There are comprehensive facilities for the provision of paediatric intensive care including high frequency oscillatory ventilation, nitric oxide treatment, paediatric and neonatal cardiac rescue ECMO, peritoneal dialysis, haemo-filtration and intracranial pressure monitoring.
The Bristol PICU has been approved for training in Paediatric Intensive Care Medicine by the Inter-College Committee of the Royal College of Anaesthesia, Paediatrics and Surgery.
Paediatric critical care transport is now undertaken by a jointly commissioned South Wales and South West Transport Service (WATCh). This service was launched on 1st September 2015, and last year 550 children were transferred to both Bristol and Cardiff (50% retrievals at level 3).
Staff involved in the Paediatric Intensive Care Unit
Dr Matt Christopherson (Director)
Dr Ines Bastista Gomes
Mr Andrew Parry
Dr James Fraser
Dr Patricia Caldas
Mr Massimo Caputo
Dr Peter Davis
Dr Catherine Armstrong
Mr Serban Stoica
Dr David Grant
Dr Guido Pieles
Mr Shaffy Mussa
Dr Suzy Dean
Dr Graham Stuart
Dr Sarah Goodwin
Dr Demetris Taliotis
Dr Adrian Humphrey
Dr Cecilia Gonzalez Bartalay
Dr Dora Wood
Dr Srinivas Narayan
Dr Omer Aziz
Dr Christopher Stutchfield
Dr Alvin Schadenberg
Dr Thomas Jerrom
Dr Will Marriage
Dr Juli Talmud
NURSING
Sarah Britton (Matron)
On PICU the trainee medical staff consists of a mixture of ST2-8 training posts and clinical fellows from multiple specialties but principally paediatrics, ICM and anaesthesia. They are responsible to the Consultants in Paediatric Intensive Care for the management of patients on the unit. A system of patient allocation is operated so that each doctor is likely to have primary responsibility for 3-4 patients during any period of daytime duty. The unit is supervised by a named Consultant Intensivist for a period of one week. During this time the Consultant supervising the unit will have no other duties. A rota of night time cover is operated so that the unit is always covered by a named Consultant in Paediatric Intensive Care, and a second consultant is responsible for the WATCh retrieval service. The care of patients will be co-ordinated by the lead consultant, and care plans are discussed with the responsible middle grade doctor on the daily ward round.
There are a minimum of 18 junior doctors/ANPs attached to PICU at any one time. PICU operates a shift based rolling rota system, which is compliant with the new junior doctor contract.
In addition to duties on the PICU, every effort is made to ensure that the trainees are able to attend educational activities (of which many are directly related to the work of the PICU). It is recognised that these requirements are likely to vary according to the background and previous experience of appointees.
The Doctor in training accepts that he/she will also perform duties in occasional emergencies and unforeseen circumstances at the request of the appropriate consultant, in consultation where practicable with his colleagues both Senior and Junior. It has been agreed between the Professions and the Department of Health that while juniors accept that they will perform such duties, the Secretary of State stresses that additional commitments arising under this sub-section are exceptional, and in particular that juniors should not be required to undertake work of this kind for prolonged periods or on a regular basis.
Programme of Education/Learning outcomes in Critical Care Medicine
During their time in post, the trainees will be expected to assimilate the following knowledge and skills. It should be emphasised that this list is not exhaustive and represents a minimum level of skill which we hope to impart. It is recognised that many doctors will come to the post with a number of pre-existing skills and every effort will be made to complement these skills by flexible application of the training component of the post.
Knowledge/Understanding:
The intensive care environment – philosophy, differences from standard care, criteria for admission.
Disruption of normal physiology by multi-organ involvement in critical illness.
The pharmacology and indications for commonly used induction/anaesthetic/sedative agents.
The Principles of pain relief.
Assessment of the airway/breathing and indications of respiratory support.
Knowledge and understanding of different modes of ventilation in children (including high frequency, extracorporeal systems, pulmonary vasoactive agents)
Pathophysiology of the heart and circulation. Disruption of the normal physiology in congenital heart disease and following commonly performed cardiac surgical procedures.
Circulatory monitoring and support.
An understanding of the mechanisms of normal cerebral homeostasis and its disruption in critical illness/injury.
Psychological support for the child/family with critical illness (including bereavement counselling)
Practical Skills:
Basic Life Support
Advanced Paediatric Life Support (for trainees who do not hold an APLS provider certificate we will try to arrange a place on a local course).
Intubation and ventilation of infants and children.
Intraosseous access, central venous cannulation, arterial cannulation.
Neurological assessment of critically ill children, including interpretation of EEG; intracerebral pressure monitoring.
Renal support (including acute peritoneal dialysis, haemofiltration).
Transportation of the critically ill infant and child.
Non Clinical Skills:
Trainees are encouraged to take part in the monthly PICU business meeting and the multidisciplinary critical incident review. In addition graded managerial experience is offered to senior trainees in the form of consultant shadowing, attendance at trust management events and involvement with rota and workforce planning. PICU operates with an ethos of open discussion regarding management decisions both on working ward rounds and during meetings such as the daily retrieval review meetings. Trainees are encouraged to understand the pressures and processes which underpin decision making.
Ward Rounds:
Three consultant led rounds are undertaken each day on PICU. Trainees present the patients on these rounds and are encouraged to present management plans. In addition there is a mid evening handover round (9pm) which is generally led by the trainees, with a consultant round taking place later in the evening/night.
Educational Opportunities
The following activities take place on PICU on a regular basis:
Daily Retrieval Review Meeting-review of patients referred to and transported by WATCh transport team (takes place at WATCh headquarters)
Weekly
• Intensive Care Core Tutorials – Tuesday pm: a system based teaching of Intensive Care Medicine by PICU Consultants and other specialist teams.
• PICU Grand Round – Wed 1200. Presentation of case or difficult dilemma from PICU
• PICU Journal Club – Thursday 1500
• Ward round/seminars – Daily Microbiology and Radiology review. Microbiology Grand Round on Thursday 1100
• Cardiac Data Presentation – multidisciplinary review of cardiac cases for coming week. Every Monday and Friday
Monthly
Wednesday afternoon meeting schedule
• Clinical Governance Meetings – monthly review of all potential/actual critical incidents from preceding month. This has now run for many years within PICU and has effected many changes to working practice within the unit. It is a totally multidisciplinary process and operates with anonymity but a “fair blame” system, whereby incident involving a trainee in which practice could be improved will either have been dealt with at the time or information passed to the educational supervisor who will use their professional discretion as to whether any further action / training is required. This process is highly valued by our staff group as being instrumental in improving practice in determining appropriate clinical governance activities such as audit and guideline development.
WATCh has a separate monthly governance meeting
• PIC Business Meetings – monthly multidisciplinary meeting looking at unit activity with contributions from allied health professionals and management
• WATCh/PIC integrated meeting – Joint meeting of WATCh transport service and PIC unit to discuss any issues relating to specific patients or more generally to the combined working of the two services
• Research/ Audit Meetings – Monthly meetings bringing together current areas of research occurring on and associated with the unit and looking ahead to future projects.
• PICU Quality and Safety Improvement meeting – Monthly group meeting:
o To facilitate the development of good multidisciplinary clinical practice on PICU.
o To facilitate the implementation of current and future guidelines.
o To facilitate communications between groups of staff who participate in changes to clinical practice on PICU.
o To oversee a programme of Quality and safety Improvement within PICU.
• PICU Education day - Monthly day of education with different talks covering some of the key PICU topics, departmental meetings and session supporting junior medical staff
• PICU Simulation Based training programme – monthly all day simulation programme run on PICU for PICU trainees
• HDU operational group – meeting to look at aspects of each area within HDU with a focus on individual elements as well as common themes. Quarterly there is an audit focus to this meeting
• Child Death Review Meetings - Attended by members of the PICU staff and other interested teams. In addition, the PICU contributes to the Children's Hospital monthly audit programme and the cardiac monthly audit on a twice per year basis. PICU is also actively involved in the National Confidential Enquiry into Maternal and Child Deaths (CEMAC) review (lead by Dr Alvin Schadenberg)
• Hospital Audit/ Clinical Governance Meeting – half day meeting held 10 times per year on rolling cycle of days.
It is expected that trainees will take an active part in the above events. Trainees are actively encouraged to attend and participate in the unit business meetings and the very active critical incident programme.
Other related educational activities in Bristol Children’s Hospital:
Weekly
• BRHC Grand Round (1 hour) – Friday 1pm in the Education Centre. Cases presented by all specialist teams on rotation.
• Paediatric SHO teaching; Weekly teaching on all core paediatric topics based on the MRCPCH curriculum
• Journal Club (1 hour) - a review of current general paediatric literature (run by gastroenterology team)
• Anaesthesia Tutorial (1 hours) – Wed am
Induction
All trainees new to UH Bristol must attend the trust induction session on Day 1. An induction to working on PICU includes introduction to working practices, key staff and vital pieces of equipment. In addition trainees are sent a link to an online learning platform before commencing the post, giving details of working on PICU, rotas and teaching programmes, procedural log and back ground reading on sedation in PICU, looking after paediatric cardiac patients and an introduction to anaesthetic agents.
Audit and Research
There is an active multidisciplinary audit programme operating within PICU under the supervision of Dr Chris Stutchfield. All projects are registered with the hospital audit department. All trainees are encouraged to take part in a project of some sort during their PICU post.
Dr Alvin Schadenberg leads the PICU research programme, with strong support from other consultants and research nurses. There are opportunities for research at various levels within PICU.
Educational Supervision and Training
Training needs and level of supervision is individualised to the trainee’s requirement. It is therefore not our policy to discriminate between the trainees on the basis of their title, as previous experience of different aspects. All junior medical staff on PICU will be allocated an Educational Supervisor for the duration of their time on the unit.