Critically ill children often present to their local hospital, which may not be equipped to provide Level 3 (intensive) care. These children are stabilised locally and then transferred to tertiary centres for ongoing care. This often involves admission to critical care units. In any given DGH, this may happen a couple of times a month.
Resident doctors at our district general hospital (DGH) highlighted a gap in the feedback process. Despite a relatively high number of transfers to tertiary centres, staff involved in these cases rarely received feedback on their management or had the opportunity to reflect on areas for improvement in future similar scenarios.
We hold a regular “Critically Ill Child Meeting”, where complex cases and inter-hospital transfers are reviewed by a multidisciplinary team, including Paediatric, Anaesthetic, and Emergency Medicine Consultants, alongside Advanced Clinical Practitioners. These meetings generate valuable learning points, which are often actioned. However, there is no formal system for sharing these insights with resident doctors and other paediatric staff who are unable to attend.
How did we improve?
To address this gap and enhance learning from critical cases, we adopted a Plan–Do–Study–Act (PDSA) approach, aiming to improve both staff education and the quality of care provided to our patients.
In response to the concerns raised, we conducted a staff survey to explore current experiences around feedback and shared learning. The survey asked whether staff had ever received feedback on their care of critically ill children, if they were aware of any learning from such cases being shared, and how they would prefer learning points to be communicated in the future.
A total of 27 staff members responded to the survey. Over half (52%) reported never having received any individual feedback on their care of a critically ill child. Furthermore, 70% stated they had never received formal feedback following a case discussion in the Critically Ill Child Meeting.
Suggestions for improving shared learning included regular email updates, scheduled meetings where staff could discuss cases, and face-to-face teaching sessions.
Interventions and feedback
In response, multiple initiatives were introduced to enhance learning and improve knowledge sharing across staff groups.
- Consultant debrief with staff involved
- Monthly meeting for case review
- Posters and e-mail to all staff with case summaries and learning points
- Quarterly case reviews with all staff invited
- Skill of the week
Consultant debrief with staff involved
For all cases involving the transfer of critically unwell children to higher-level care, an early debrief is held between the responsible paediatric consultant and involved staff. This discussion includes a brief case summary, a review of how the case was managed, recognition of what went well, and identification of any immediate learning points or safety issues that can be quickly addressed.
This early discussion is structured as a “hot debrief”, providing a safe, judgment-free space to reflect on the case. These debriefs often go beyond identifying clinical learning points — they frequently highlight system-level or operational changes that can be made to improve overall patient care.
A few examples of things that have been identified and addressed following these debriefs in the past 12 months include the following:
Improving referral and transfer of patients
Printed STOPP (Safe Transfer of Paediatric Patient) sheets were introduced in all clinical areas where paediatric transfers typically occur.
The STOPP sheet ensures that, before the transfer team is contacted, a relevant summary of the child’s clinical details is completed and readily available. This facilitates a smoother referral process, enables the transfer team to provide more targeted advice, and helps expedite the safe transfer of the child to the most appropriate care setting. Ensuring these forms are consistently stocked also helps prevent unnecessary delays during critical moments.
Equipment issues
In one recent case, the administration of inotropes — a rare intervention in a district general hospital (DGH) paediatric setting — was delayed due to the unavailability of suitable equipment. This issue was promptly identified during the debrief process. As a result, three-way taps appropriate for inotrope administration are now routinely stocked and readily accessible in all relevant clinical areas.
In another case, a blood crossmatch sample was rejected because it was taken in the incorrect bottle. At our hospital, different bottles are required for cross-matching children depending on their age, and not all types are routinely available within the paediatric department. Following discussion with the blood transfusion team, additional staff training was delivered, and all required bottle types are now stocked in every area where critically ill children may present.
Small issues add up! Small improvements in patient care and management made across multiple areas can add up to ensure a better result and outcome for patients.
These consultant-led debriefs also provide a valuable opportunity for clinicians to complete workplace-based assessments, supporting their professional development and portfolio requirements where appropriate.
Monthly meeting for case reviews
A monthly Critically Ill Child Meeting continues to take place, during which all recent transfers from our DGH to tertiary centres for higher-level care are reviewed.
These are structured meetings with a set agenda and accompanying supporting documentation for each case discussed. Attendance has been expanded to include resident doctors and other senior staff with an interest in the care of critically unwell children, fostering a more inclusive environment that encourages open discussion and shared learning.
Sample CIC Meeting Agenda:
Apologies
Minutes of last meeting
Review of CIC Meeting Action Log
Review of CIC Case Review Actions and Learning
Admissions to HDU and Transfers
Presentation of Case Reviews
Cases for Review at Next Meeting
Any Other Business
Minutes of previous meetings are corrected as needed.
Within a week of the event, a senior clinician who was not directly involved in the case undertakes a review of the clinical notes. This includes an assessment of the documentation, investigation results, imaging, treatments provided, and any feedback or information received from the receiving teams post-transfer.
The clinicians involved in the child’s care are contacted via email and invited to share any concerns they may have had about the case—either at the time or upon later reflection.
A case presentation is then compiled, incorporating the clinical summary, reflections from involved staff, and the reviewer’s preliminary thoughts on key learning points. These may highlight examples of excellent practice as well as areas where improvements could be made.
The case is subsequently presented at the Critically Ill Child Meeting, where it is discussed in detail with attendees and any further learning points are identified collaboratively.
Any actions arising from the case discussions are added to a dedicated action log, with specific staff members assigned responsibility for completing each task. The action log is reviewed at every meeting to ensure progress is monitored and that changes are implemented in a timely and effective manner.
The action log captures any changes identified during case reviews, which may include updating or developing new clinical guidelines, introducing or modifying equipment, or recognising the need for staff to be upskilled in specific tasks or areas.
It also includes mechanisms for disseminating learning points to all relevant staff involved in the care of critically unwell children, helping to ensure that improvements and insights are shared across the wider clinical team.
This includes:
- Staff emails and posters in non-clinical areas containing case summaries and learning points.
- Choosing Cases for discussion at quarterly review meetings with wider staff groups
- For any case where the review highlights a significant change to clinical practice, an email is circulated to all relevant staff. This includes a summary of the case, the rationale for the change, and details of the updated guidelines or new practices being implemented.
Some discoveries
Ergonomic challenges were identified in the layout of the paediatric resuscitation room in the Emergency Department, particularly regarding the positioning of monitors. The monitors were not optimally placed to allow the anaesthetic team a clear view while managing the airway. In response, the monitor positions have been reviewed and adjusted. Further simulation training is planned to help identify and address any remaining ergonomic issues, ensuring the environment supports safe and effective care.
In a recent case, an infant presenting with vomiting was later diagnosed with a posterior fossa tumour. This prompted additional staff training, focusing on the importance of considering rarer causes of vomiting in infants and children as part of the differential diagnosis. Further education and learning resources were also shared to support earlier recognition of brain tumours in children.
Quarterly case reviews with all staff invited
Cases identified as particularly valuable for wider team learning are now presented at a quarterly multidisciplinary review. All staff are invited to attend and participate in open discussion. These sessions are well attended and have received excellent feedback — with participants consistently rating the relevance as 5/5, and an average score of 4.87/5 for overall content quality. Qualitative comments described the sessions as “interactive”, “relevant to practice”, and a “great learning experience.”
Held four times a year, these reviews bring together a comprehensive team including the broader consultant body, registrars, senior house officers, nursing staff, and Advanced Nurse Practitioners. Colleagues from the Emergency Department and Anaesthetics are also invited to contribute.
Sessions are carefully tailored to the needs and experience of the audience, ensuring content remains relevant, practical, and engaging for all attendees.
To maximise the effectiveness of these sessions, they are designed to be highly interactive. Team members are actively engaged throughout, with opportunities to contribute insights and suggest management plans at various points in the discussion. At the end of each session, key learning points are summarised — including what went well, areas for improvement, and proposed changes to future practice.
Relevant national guidelines are also circulated following the session to support continued learning and help embed best practice across the team.
Examples of cases discussed and learning points
One of the cases discussed involved a teenager with a complex medical history, including a genetic condition, developmental delay, and dystonia. He presented to the Emergency Department with a reduced level of consciousness and acute kidney injury (AKI). His neurological status deteriorated, with a falling Glasgow Coma Scale (GCS) score, necessitating escalation and transfer to the Paediatric Intensive Care Unit (PICU).
Multiple specialties were involved in his care, including Nephrology, Metabolic Medicine, Neurology, Anaesthetics, and PICU. Management was focused on addressing hepatic encephalopathy, hyperammonaemia, and dystonia.
This case highlighted several key learning points, particularly around the national guidance for the management of children and young people presenting with an acute decrease in conscious level (DeCon). We supported the session with visual aids and led an in-depth discussion on the differential diagnosis, baseline investigations, and initial management strategies.
Another case involved a two-week-old infant diagnosed with congenital heart disease, who was started on Prostin and subsequently required transfer to a tertiary centre for advanced cardiology care. Following consultation with the critical care transport team, it was advised that the transfer be arranged locally by the referring hospital.
A key learning point from this case was the importance of implementing the STOPP (Safe Transfer of Paediatric Patient) tool, as outlined in the regional transport guidelines. This tool supports safe transfer by providing a structured risk assessment before transport, and offers clear guidance on transfer categorisation and the level of staffing required.
The learning was shared widely to reinforce the consistent use of the STOPP tool for all applicable transfers, ensuring both patient safety and appropriate resource allocation.
These Quarterly review meetings aim to facilitate knowledge sharing, education and dissemination of key learning points to the wider team. This will ensure the consistent delivery of high-quality care to critically unwell children.
Posters and Email to all staff with case summaries and learning points
A regular email newsletter has been introduced, featuring brief case summaries and key learning points from recent transfers. This is distributed to all paediatric medical and nursing staff to ensure learning is shared widely. In addition, posters highlighting the same points are regularly displayed in staff areas for easy reference.
The content of the newsletter and posters mirrors the learning discussed at Critically Ill Child (CIC) meetings and Grand Rounds, ensuring that staff unable to attend in person still benefit from the shared knowledge. Learning points may also originate from hot debriefs following transfers, allowing for the rapid dissemination of important safety messages or changes to local practice.
Skill of the week
A new ‘Skill of the Week’ initiative has been introduced, focusing on uncommon but important procedures or clinical scenarios that have recently presented challenges for staff. The aim is to provide regular opportunities for safe, simulated practice to improve preparedness and confidence. Recent topics have included neonatal chest drain insertion and prostaglandin prescribing — both infrequently performed in a paediatric department within a District General Hospital, yet critical when required.
Staff feedback has been overwhelmingly positive, with participants reporting increased confidence and a belief that the sessions will enhance the quality of care they deliver. Similar initiatives have been established at other hospitals within the region, making the format familiar and accessible for rotational staff.
Teaching is delivered through structured, consultant-led sessions held multiple times per week, alongside self-directed learning opportunities. Resources are made available in clinical areas for those unable to attend the live teaching, ensuring flexible access to learning for all staff.
Feedback and future plans
Our interventions have been straightforward to implement, not overly time-consuming, and have received consistently positive feedback — particularly from resident doctors. Staff report feeling supported in discussing and reflecting on complex cases involving critically unwell children, within a structured and psychologically safe learning environment.
Locally, the project continues to evolve. We are actively gathering feedback from staff to identify areas for improvement and to guide future developments. Our goal is to ensure that the process remains responsive to the needs of the team and continues to enhance learning and patient care.
Looking ahead, we are working with our regional transport team and colleagues in other hospitals to expand the project across the region. Plans are underway to develop a network-wide feedback mechanism, supported by input from the regional transport team. This will help identify common themes across different hospitals and ensure that staff in District General Hospitals receive direct feedback from transport teams. This collaborative work is ongoing, and we are optimistic about the wider impact it could have on shared learning and patient safety across the region.
