From 30 September, health professionals in NSW public hospitals will be required to ask this question to parents, family members and carers of babies and children at four key times: at the start of vital signs observations (at least every four hours), during ward rounds, at bedside clinical handovers and during medical reviews.
The question aims to capture clinical deterioration, and resources accompanying the rollout stress that the precise wording matters. Specifically, health professionals should not just ask if the parent or carer is worried, but rather if they are worried the child is getting worse.
The intervention comes on the back of a study by Monash Health published in the Lancet in July, which analysed nearly 190,000 documented responses from caregivers who were asked ‘Are you worried your child is getting worse’ during their child’s ED visit or hospital admission. Of those, just under 9000 responses, or 4.7%, answered yes.
The researchers found that caregiver concern was a better predictor of ICU admission and mechanical ventilation than any abnormal vital sign (after adjusting for potential confounders*.)
“Despite voiced concerns from clinicians that all caregivers would be worried, our findings demonstrate that the question ‘Are you worried your child is getting worse?’ elicited a yes response only once every 21 times it was asked,” the authors state, noting that this was lower than the proportion who had at least one abnormal vital sign during their stay.
“In about 19% of patients who had both abnormal vital signs and documented concern for clinical deterioration, the concern was documented before the abnormal vital sign.”
In the study, when caregivers answered yes to the initial question, clinicians then asked “What has changed? And what are you concerned about?’ to gauge whether the concern was regarding clinical deterioration.
Concerns about clinical deterioration were then reviewed by a bedside nurse and treating doctor within half an hour, and further escalated if the concern was not addressed at that stage.
A previous study in primary care found that when a parent was concerned that “this illness is different” their child was more likely to have a serious bacterial infection, but the link wasn’t seen when the study was repeated in a tertiary ED.
Dr Erin Mills, a paediatric emergency medicine physician and lead author of the Lancet study that prompted NSW to require the intervention, says the process could be particularly valuable in primary care.
“In primary care you are using the parent to determine the child’s illness trajectory in the community – this could even potentially be more useful in that setting,” Dr Mills says.
“The key is in finding out if the concern is about clinical deterioration, which generally requires a follow up question after the first and some clinical judgement to be applied.”
Dr Mills says the team is “currently researching the utility in adults in general, CALD patients and older adults.”
Although the results are forthcoming, she is optimistic.
“I think this will be very useful in most patient groups – and there is not much harm in asking the question.”
Worried they’re getting worse? Information for clinicians
* The researchers adjusted for age, gender, socioeconomic status, primary language, country of birth, indigenous status, mode of arrival, Australasian Triage Scale category and abnormal heart rate, respiratory rate, oxygen saturation, blood pressure, or conscious state.
Listen to expert interviews.
Click to open in a new tab
Browse the latest articles from Healthed.
Once you confirm you’ve read this article you can complete a Patient Case Review to earn 0.5 hours CPD in the Reviewing Performance (RP) category.
Select ‘Confirm & learn‘ when you have read this article in its entirety and you will be taken to begin your Patient Case Review.
