The Evelina Resolution Project: the story of a UK children's hospital's programme to resolve conflicts with families

When a consultant paediatrician at the Evelina London Children's Hospital made a phone call to a mediator one Friday afternoon in 2012 asking for help to manage an escalating conflict between a family and the health professionals treating their daughter, neither knew that their meeting would lead to the development of the first conflict resolution and mediation training programme in a National Health Service children's hospital.  The Evelina Resolution Project has gained international recognition for training health professionals to recognise and manage conflicts between families and health professionals.  In this presentation, the doctor and the mediator describe how one case led to a programme of change which is now being trialled in 4 specialist UK children's hospitals with the aim of supporting families and health professionals to have conversations without conflict

A Taster Of An Award-Winning Conflict Resolution Training Program For Pediatric Health Professionals

In 2013, the Medical Mediation Foundation and the Evelina London Children’s Hospital initiated a project to explore the nature and impact of conflict across paediatrics. Interestingly, staff were initially reluctant to name disagreements as ‘conflict’, but widespread canvassing of experience yielded a working definition of conflict which has ‘the breakdown of trust and communication breakdown’ and "impact on the ability of staff to provide optimal care to the child" at its core.  The project, based on published research with families and health professionals, provides training to staff in recognising and managing conflict and an independent mediation service available to families, patients and staff to help resolve conflict if it escalates. The Evelina Resolution Project has become a nationally recognised, award-winning training programme.  Interactive, multi-disciplinary sessions (usually half days, 12-20 staff) are co-trained, combining the expertise of a senior consultant paediatrician and an experienced accredited mediator. Six month follow up of a cohort of 313 staff found that more than half had experienced a conflict with a parent or patient since doing the training and of these,  95% reported that the training  had helped them to recognise the warning signs and 91% said it had helped de-escalate the conflict. Feedback from more than 1600 Evelina staff trained to date, provides consistently high ‘quality’ ratings (95% rated the training as excellent/very good), ‘relevance’ ratings (99% - very relevant/relevant) This workshop will offer a condensed version of the training and an opportunity for participants to practise and discuss the skills taught.

Conflict in a paediatric hospital: a prospective mixed-method study

Background Conflict in healthcare is a well-recognised but under-examined phenomenon. Little is known about the prevalence and causes of conflict across paediatric specialties.  Objective To report the frequency and characteristics of conflict in a paediatric hospital.  Design and setting An explanatory sequential mixed-method approach was adopted. A bespoke questionnaire recorded frequency, severity, cause and staff involved in conflict prospectively. Data were recorded for the same two 12-week periods in 2013 and 2014, in one UK children's teaching hospital. Data were analysed using descriptive statistics and correlation, the findings of which informed the construction of a semistructured interview schedule. Qualitative interviews were conducted with six key informant healthcare professionals to aid data interpretation; interviews were analysed thematically.  Results 136 individual episodes of conflict were reported. The three most common causes were ‘communication breakdown’, ‘disagreements about treatment’ and ‘unrealistic expectations’. Over 448 h of healthcare professional time was taken up by these conflicts; most often staff nurses, consultants, doctors in training and matrons. The mean severity rating was 4.9 out of 10. Qualitative interviews revealed consensus regarding whether conflicts were ranked as low, medium or high severity, and explanations regarding why neurology recorded the highest number of conflicts in the observed period.  Conclusions Conflict is prevalent across paediatric specialties, and particularly in neurology, general paediatrics and neonatology. Considerable staff time is taken in managing conflict, indicating a need to focus resources on supporting staff to resolve conflict, notably managing communication breakdown

Transforming training into practice with the conflict management framework: a mixed methods study

Objective To implement and evaluate the use of the conflict management framework (CMF) in four tertiary UK paediatric services. Design Mixed methods multisite evaluation including prospective pre and post intervention collection of conflict data alongside semistructured interviews. Setting Eight inpatient or day care wards across four tertiary UK paediatric services. Interventions The two-stage CMF was used in daily huddles to prompt the recognition and management of conflict. Results Conflicts were recorded for a total of 67 weeks before and 141 weeks after implementation of the CMF across the four sites. 1000 episodes of conflict involving 324 patients/families across the four sites were recorded. After implementation of the CMF, time spent managing episodes of conflict around the care of a patient was decreased by 24% (p < 0.001) (from 73 min to 55 min) and the estimated cost of this staff time decreased by 20% (p < 0.02) (from £26 to £21 sterling per episode of conflict). This reduction occurred despite conflict episodes after implementation of the CMF having similar severity to those before implementation. Semistructured interviews highlighted the importance of broad multidisciplinary leadership and training to embed a culture of proactive and collaborative conflict management. Conclusions The CMF offers an effective adjunct to conflict management training, reducing time spent managing conflict and the associated staff costs

Time to Switch to Second-line Antiretroviral Therapy in Children With Human Immunodeficiency Virus in Europe and Thailand.

Background: Data on durability of first-line antiretroviral therapy (ART) in children with human immunodeficiency virus (HIV) are limited. We assessed time to switch to second-line therapy in 16 European countries and Thailand. Methods: Children aged <18 years initiating combination ART (≥2 nucleoside reverse transcriptase inhibitors [NRTIs] plus nonnucleoside reverse transcriptase inhibitor [NNRTI] or boosted protease inhibitor [PI]) were included. Switch to second-line was defined as (i) change across drug class (PI to NNRTI or vice versa) or within PI class plus change of ≥1 NRTI; (ii) change from single to dual PI; or (iii) addition of a new drug class. Cumulative incidence of switch was calculated with death and loss to follow-up as competing risks. Results: Of 3668 children included, median age at ART initiation was 6.1 (interquartile range (IQR), 1.7-10.5) years. Initial regimens were 32% PI based, 34% nevirapine (NVP) based, and 33% efavirenz based. Median duration of follow-up was 5.4 (IQR, 2.9-8.3) years. Cumulative incidence of switch at 5 years was 21% (95% confidence interval, 20%-23%), with significant regional variations. Median time to switch was 30 (IQR, 16-58) months; two-thirds of switches were related to treatment failure. In multivariable analysis, older age, severe immunosuppression and higher viral load (VL) at ART start, and NVP-based initial regimens were associated with increased risk of switch. Conclusions: One in 5 children switched to a second-line regimen by 5 years of ART, with two-thirds failure related. Advanced HIV, older age, and NVP-based regimens were associated with increased risk of switch

Umbilical cortisol levels as an indicator of the fetal stress response to assisted vaginal delivery

Objectives: While it is well established that delivery by elective caesarean section is less stressful for the fetus than normal vaginal delivery, little attention has been paid to the effect on the baby of an assisted delivery

Reactivity of Routine HIV Antibody Tests in Children with Perinatally-Acquired HIV-1 in England: Cross Sectional Analysis.

We assessed HIV antibody prevalence in children with perinatally-acquired HIV (PaHIV) in England. 18%(10/55) of those starting combination antiretroviral therapy (cART) <6 months of age were seronegative, and had lower viral load at diagnosis and cART start, and fewer viral rebounds, than 45/55 seropositives. Implications for patient selection for HIV cure research, and interpretation of routine antibody testing, are discussed

Characteristics of invasive staphylococcus aureus in United Kingdom neonatal units

BACKGROUND: In industrialized countries, Staphylococcus aureus (SA) is a leading cause of late-onset neonatal sepsis. METHODS: Culture-proven episodes were identified prospectively from neonatal units participating in the neonatal infection surveillance network. Demographic, risk factor, and outcome data were collected. RESULTS: Between 2004 and 2009, there were 117 episodes of SA infections (including 8 methicillin-resistant SA) in 116 infants from 13 units. The median gestational age and birth-weight were 27 weeks (90% ≤37 weeks, 85% ≤32 weeks) and 850 g (90% ≤2500 g), respectively. The overall incidence was 0.6 per 1000 live births and 23/1000 in infants <1500 g. Most episodes (94%) occurred more than 48 hours after birth (late onset). There were 7 early-onset episodes (<48 hours) (median gestational age, 38.5 weeks), all due to methicillin-susceptible SA. At the time of culture, 67 of 95 (71%) infants were receiving respiratory support and 47 of 94 (50%) had a central line in situ. The majority of infants had nonspecific clinical features although evidence of focal infection (skin, soft tissue, bone, joint, or pneumonia) was ultimately seen in 41 of 91 (45%). There were 18 deaths, 4 (all late onset) directly due to methicillin-susceptible SA sepsis (4.4%). CONCLUSIONS: SA is the second most common pathogen causing late-onset neonatal infections in this neonatal network. Infants who weigh <1500 g in intensive care settings are the most vulnerable group. Clinical signs are not sufficiently distinctive to allow targeted therapy, suggesting that an antistaphylococcal agent should be part of empiric therapy for late-onset sepsis in premature infants