Delivering Quality and Value

Focus on: Children andYoung People Emergencyand Urgent CarePathway

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Document Purpose Best Practice Guidance

ROCR Ref: Gateway Ref: 10093

Title Focus on: Children and Young People Emergency and Urgent Care Pathway

Author NHS Institute for Innovation and Improvement

Publication Date 26 June 2008

Target Audience PCT CEs, NHS Trust CEs, SHA CEs, Foundation Trust CEs, Medical Directors,Directors of Nursing, PCT PEC Chairs, NHS Trust Board Chairs, GPs, EmergencyCare Leads, Directors of Children’s SSs, All clinicians specialising in paediatrics

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Description This document is one of a series of documents produced by the NHS Institutefor Innovation and Improvement as part of our High Volume Care programme.Produced by the Delivering Quality and Value Team, the aim of the Focus onseries is to help local health communities and organisations improve the qualityand value of the care they deliver.

Cross Ref High Volume Care: Update

Superseded Docs

Action Required n/a

Timing

Contact Details NHS Institute for Innovation and ImprovementCoventry HouseUniversity of Warwick CampusCoventryCV4 7AL

www.institute.nhs.uk

For Recipient’s Use

Clinical

Contents:

Foreword

1. Introduction

2. Understanding the variation

3. Children and young people emergencyand urgent care pathway

4. The overarching characteristics oforganisations providing high qualitycare and value for money

5. Pathway specific characteristics

6. Benefits

7. Conclusion

8. Acknowledgements

9. Further reading and references

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Children and young people in England require highquality emergency and urgent care when they are illor injured. Prompt access to face to faceconsultation with a skilled, competent andconfident professional is expected by families.

Whilst there has been significant improvement inemergency and urgent care services since thepublication of the National Service Framework forChildren, Young People and Maternity services andthere are more child friendly facilities with morestaff trained to care for children, there is furtherimprovement needed. The Healthcare Commissionreviewed progress and found there was more to do,particularly in departments whose focus was notprincipally on children or young people.

The NHS Institute for Innovation and Improvementhas produced a document which has identifiedareas of innovative practice that are in the area ofemergency and urgent care for children and youngpeople which merit further study. There is no simplesolution for all organisations, but there are a varietyof valuable service improvement ideas in thisdocument that could be selected and modified foruse locally.

The key to providing high quality emergency andurgent care for children and young people are stafftrained and skilled, clear patient pathways, usingbest practice and supported by a network. Thecommissioners and providers of services should worktogether ensuring coordination between GPservices, urgent care and out of hours services, walk-in centres, ambulance services, emergencydepartments and paediatric departments.

The optimum configuration and location of servicesshould be determined locally, based on the needs ofthe population and after consultation with users ofthe service, aiming to avoid unnecessary admissionsand inappropriate delays in discharge and ensuringhigh quality and safety, the optimum use of skills inthe workforce, seamless care, efficiency and valuefor money.

I am pleased to hear that the NHS Institute forInnovation and Improvement has produced anumber of products to accompany this documentthat should help to turn some of the ideas intopractical solutions. I hope that this report will bewidely read and contribute to improvements inservices for children, young people and theirfamilies ensuring best clinical outcomes andoptimum child and family experience at what canbe a challenging time.

ForewordBy Sheila Shribman

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National Director for Children,Young People and Maternity Services

This document focuses on theemergency and urgent carepathway for children and youngpeople with the most commonillnesses and injuries.

The programme is based on theconcept that, by focusing on alimited range of high volumepathways, the NHS Institute canhelp the NHS make the maximumimpact on improving the qualityand value of care for NHSpatients.

To do this it has been essential forthe programme to:

• be clinically led

• engage with a wide range ofclinical and managerialprofessionals

• be co-produced with the NHS

• be integrated with other NHSinitiatives.

The aim is a paradigm shift inclinical efficiency andeffectiveness, resulting in localhealth systems being able toprovide clinically effective andcost efficient, safe healthcare forthe benefit of children and youngpeople.

1. Introduction

About the Focus on seriesThis document is one of a series published by theNHS Institute for Innovation and Improvement aspart of our High Volume Care programme.Produced by the Delivering Quality and ValueTeam, the aim of the Focus on series is to helplocal health communities and organisationsimprove the quality and value of the care theydeliver.

The areas we are focusing on in the programmehave been selected because: they are high volume(and therefore high consumers of NHS resources),they show variability in their use of resources andthey represent a range of clinical areas.

To find out more about the programme and theFocus on series see the Delivering Quality andValue pages at: www.institute.nhs.uk

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1 Co-production with the NHS, involving all sites visited and national bodies and experts relevant to the pathway.

The approach

A literature review wasundertaken of the recognisedevidence in delivering optimisedcare for children requiringemergency and urgent care. The‘References’ section at the end ofthis document gives further detailof the documentary evidence.

A thorough data analysis wasundertaken using nationallyavailable data from the HospitalEpisode Statistics. This data wasused to rank and identify thehighest performers, using averagelength of stay spell as a proxyindicator (‘spell’ refers to thelength of time a patient stays inan acute hospital setting).

There is limited data availableregarding the pathway outsidethe hospital, for example thenumber of attendences in walk-incentres and primary urgent carefacilities. To look at the wholepathway we used ‘soft’intelligence from various sources,including professional networks,to identify innovative practice.This approach allowed us toidentify organisations who weredelivering high quality andefficient care.

Verifying the selection oforganisations

Having identified the local healthand social care communities, weapproached organisations to visitand observe how they managethis group of patients. The‘Acknowledgements’ section atthe end of this document lists theorganisations we visited. Theinformation contained within thispathway was only possiblebecause health and social carecommunities allowed us to seetheir practice.

We then undertook visits,ensuring that at least 50 per centof our time was spent observingthe flow and processes of care,including clinical decision makingand the use of information to aidclinical and non-clinical decisionmaking. The remaining time wasspent conducting a series of semi-structured interviews with keymembers of staff across thepathway of care (including arange of doctors, nurses,ambulance staff, pharmacy staff,primary care staff, communityservices staff, information staff,executive teams, managers andcommissioners). In total weinterviewed at least 150 staff andobserved over 300 staff in 115different areas (clinical and non-clinical) for this pathway.

The knowledge we gained fromthese visits and the co-productionevents1 was then consolidated,and the optimised pathway ofcare, illustrated later in thedocument, was identified.

We worked in partnership withthe NHS throughout this projectto validate the pathway and toidentify improvement measuresthat would be helpful indicatorsfor evaluating the impact ofchange.

Prototypes have been identifiedand tested with the NHS tomaximise adoption. Some ofthese will follow on from thepublication of this document,such as a toolkit to help providersengage children, young peopleand families in all aspects ofplanning and delivering theservices, as well as seekingfeedback from them. The keycharacteristics for deliveringoptimal care in the NHS havebeen tested with theorganisations and others toensure that the change inpractice is understood, is relevantand appropriate and thatmeasuring the improvement ispossible within a short timeframe.

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How to use this document

The content of this document hasbeen developed with the help ofNHS staff for the benefit of anyorganisations and stakeholdersthat play any part in the childrenand young people emergency andurgent care pathway.

Implementation will havenumerous benefits for childrenand young people and all theirhealth services because managingemergency and urgent careprocesses well will have a knock-on effect on all other processes.

The improvements in theemergency and urgent careprocesses described in thisdocument have the potential toresult in a significant increase inthe number of children andyoung people managed inambulatory settings. Ambulatorycare is defined as inpatient careprovided in non-inpatient orcommunity settings.

In each section of the documentthere is a list of useful measuresthat may be used in order toassess your current performancein providing a successfulemergency and urgent service forchildren and young people. It isimportant to regularly monitorperformance, as this providesuseful feedback on any changesyou make to the pathway.

Most of the data for themeasures described can beobtained from your informationdepartment. Other ‘softer’ data,such as surveys, will need to bedeveloped inhouse/locally.

Context

Children and young people haveunique emergency and urgenthealth care needs. They aredifferent from adults in anatomy,physiology and psychology. Theypresent with a different range ofclinical problems and symptoms,which may not be familiar toprofessionals who work only withadults.

Children and young people’sability to communicate dependson their age and stage ofdevelopment. However, as ageneral rule, children and youngpeople tend to act younger whenthey are unwell.

Children and young peopleshould be cared for inenvironments that are specificallydesigned for their needs whichare separate from adult caresettings. Play is seen as a right forall children and young peopleand they need access to ageappropriate play facilities andrecreational activities whereverthey are looked after.

It is often quoted thatchildren are not just miniadults needing smallerbeds and smaller sizedportions of food in thehospital, yet their needsare often not taken intoaccount

Key characteristics havebeen developed with theexpectation that they willbe widely adopted acrossthe NHS so that childrenand young people receivea high quality experienceirrespective of where theyreceive their care

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Every professional who is involvedin the care of a child and/oryoung person, should, as aminimum, be competent in:

1. * recognition of the sick child

2. * basic life support skills

3. * initiation of treatment usingprotocols for themanagement of commonconditions

4. * recognition of rare buttreatable conditions

5. effective communication

6. recognition of and responseto any concerns aboutsafeguarding

7. understanding the need forplay and recreation activities.

The majority (80%) of episodes ofillness in children are managed bytheir families without cominginto contact with any health

professionals.2 Children, youngpeople and families nowadays usea variety of sources, such as NHSDirect or the Internet, to accessinformation and support.

If children and young peopleneed face to face consultation,they may visit a range of settingssuch as a pharmacy, GP practice,walk-in centre, emergencydepartment, or children’sassessment unit. Care is providedby a number of professionals, forexample, GPs, practice nurses,children’s nurses andpaediatricians. When developingservices there needs to beeffective workforce planningbetween children’s services,commissioners and providers ofeducation and training to ensurethe supply of an affordable andsustainable workforce for thefuture.

Children and young people inneed of emergency and urgentcare present initially withundifferentiated problems, withnon-specific symptoms.

States Parties recognize the right of the child to rest and leisure, to engage inplay and recreational activities appropriate to the age of the child and toparticipate freely in cultural life and the arts.

Source: ‘United nations convention of the rights of the child’ article 31

http://www.unhchr.ch/html/menu3/b/k2crc.htm

* Royal College of Paediatrics and Child Health (RCPCH) ‘Modelling the Future - A consultation on the future of children’s health services’ (September 2007) p35http://www.rcpch.ac.uk/Health-Services/ServiceReconfiguration/Modelling-the-Future

2 ‘Getting the right start: National Service Framework (NSF) for Children, Young People and Maternity Services: Standard for hospital services’ (April 2003),Standard 6, 2.1, p6.

Skilled assessment by anexperienced and trainedprofessional, sometimescoupled with a shortperiod of observation, isneeded to differentiate aminor condition from alife-threatening condition

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There is a small sub-group ofvulnerable children and youngpeople who have very specificneeds and are likely to be at riskof repeat admissions and, eitherstay for a long time on achildren’s ward, or wait for a bedin a specialist unit. This groupincludes those with severe neuro-disability, complex co-morbidities,mental health needs and alsothose in need of palliative care.The care of many of thesechildren and young people couldbe improved by having proactivecommunity children’s nursingteams who can predict andrespond to emergency and urgentcare needs.

A small but significant minority ofchildren and young people areseen by healthcare professionalswho have concerns about theirsafety. This could be because ofintentional injury, sexual harm orphysical and emotional neglect.

Recognising and responding toconcerns about safeguarding is anintegral part of any system that isset up to deal with this pathway.

Appropriate management in thecommunity setting, close to achild’s home, will preventunnecessary travel, unnecessaryadmissions and, potentially, longwaits. Good quality care,delivered closer to home, is goodfor the children, good for thefamily and is often cost effective.

This approach where children andyoung people are looked after athome whenever it is possible andsafe to do so, and are onlyadmitted where there are clinicalreasons, fits well with theambulatory model of care.

This model can only be deliveredthrough a children’s emergencyand urgent care clinical networkwith a clear pathway, shared

guidelines and standards,integrated commissioning,monitoring and inspection. Allchildren’s health systems need tobe integrated with education andsocial care.

The National Service Frameworkfor Children, Young People andMaternity Services (2003) setsclear standards for children’shealth services. The Health CareCommission3 conducted a reviewof services for children in hospitalin 2006 and found that eventhough progress is being made inimproving services, only 4% oforganisations (n=6) were rated asexcellent, 21% as good (33), 70%as fair (110), and 5% as weak (8)highlighting the need for furtherimprovements in this area.

3 ‘Improving services for children in hospital’, the Healthcare Commission (February 2007).

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Understanding the variation inemergency and urgent care forchildren and young people.

More than three million children(equivalent to 28% of all childrenin England aged 0-16) attendedemergency departments in2006/7, accounting for more than25% of all patients seen.

The number of children andyoung people aged 0-16 yearsbeing admitted throughemergency departments is over350,000 and has risen by 6.8%over the last three years.

The following graph (Figure 1)shows a significant variation inthe percentage of emergencyadmissions by trust for children 0-16 years of age for 2006/7.

Figure 1: percentage of emergency admissions by trust for children 0-16 years of age for 2006/7

2. Understanding the variation

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4 Source: Hospital Episode Statistics for calendar year 2006/2007.

There has been an increase in thenumber of children with a lengthof stay (LOS) of zero (an episodeof care without an overnightstay). In 2004/5 the number was320,874, and by 2006/7 it had

risen to 369,690 (an increase of15%)4 suggesting that aproportion of these childrencould be managed in thecommunity if appropriate skillsand facilities to assess, treat and

observe them were available.Figure 2 shows the variation forLOS of 0 - 2 days as a percentageof all emergency admissions(excluding obstetrics andgynaecology) by trust.

Figure 2: variation for LOS of 0-2 days as a percentage of all emergency admissions (excluding obstetricsand gynaecology) by trust

60.00%

65.00%

70.00%

75.00%

80.00%

85.00%

90.00%

95.00%

Trust

% of Emergency Admissions

% of all emergency admissions aged 0-16 with LoS between 0 and 2 days Mean

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In 2006/7 the mean LOS was 2.26days, but the following graph(Figure 3) shows there is stillsignificant variation in length ofstay between organisations across

the country, ranging from 1.06 to5.08 days.

Figure 3: variation in length of stay between organisations across the country, ranging from 1.06 to 5.08 days.

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In 2006/7, 304,458 emergencyadmissions had a LOS of betweenone and two days and 113,602had a LOS over two days.

The increasing high volume ofchildren and young peopleneeding emergency and urgentcare, coupled with the significantvariation in the LOS, offers anopportunity for someorganisations to provide bettercare more efficiently.

By reducing the LOS of patientswho stay between one and two

days (by an average of half aday), there are potential savingsof at least £53 million (excludinglength of stay of zero). This canbe achieved through a variety ofmechanisms, some of which aredetailed in this document. Thesavings could be at least £161million if the LOS for patientsstaying more than two days isreduced by one day.5

Organisations can further reducecosts associated with zero lengthof stays by developingambulatory services. However,

organisations need to considerthe potential costs involved indelivering these alternativeservices.

The savings could be atleast £161 million if thelength of stay for patientsstaying more than twodays is reduced by oneday

5 Figures calculated by Dr Foster Intelligence using data from Secondary UserServices (SUS), using £228 as excess bed day tariff.

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For simplicity, the pathway startsafter the point at which childrenand young people should beaccessing services delivered byprimary care’s urgent careprocesses (such as localpharmacists, NHS Direct, out ofhours services, GPs and walk-incentres). However, the key todelivering effective emergencyand urgent care is ensuring that

the whole system is designed tosupport self care and communitycare at home, thereby avoidingunnecessary hospital admissionsand facilitating timely earlydischarges.

Once children and young peoplepresent in secondary care everyattempt should be made tominimise admission rates and LOS

by providing early comprehensiveassessment and treatment byexperienced and competentchildren’s nurses and doctors.To achieve this, the interfacebetween hospital and communitycare is crucial and should besupported by an integratedinformation system across thepathway.

3. Children and young people emergency andurgent care pathway

* Minor illness, Minor Injury Unit **Child and Adolescent Mental Health Service

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The following characteristics havebeen found to be the keyfeatures for delivering qualityand value for emergency andurgent care services for childrenand young people. They areillustrated by case studies fromthe health communities visited.

The case studies are followed bysome suggested measures forimprovement which have beenco-produced with ourstakeholders. These are offered asa prompt to encourageorganisations to benchmark theircurrent practice against thecharacteristics described, and tofurther improve their services.

Some of the data described canbe obtained from localinformation departments.However, organisations may needto develop new systems forcollecting and using relevantmeasures. To measure qualitativeinformation, surveys will have tobe designed and the responsesanalysed.

4. The overarching characteristics of organisationsproviding high quality care and value for money

Overarching characteristics

Key characteristic 1:Clinical leadership isempowered and there isan enlightened executiveteam.

• A high profile children’s servicewhich is led by clinical and non-clinical leaders

• The executive team engageswith staff in clinical areas

• Collaborative leadershipbetween managers andclinicians is promotedthroughout the organisation

• The trust board understands theunique challenges facingchildren and young people’sservices by recruiting a youngperson as a trust boardgovernor.

‘We are encouraged to collect accurate data,analyse patient flows and find any problemsthat affect the quality of care and delays intreatment. We are encouraged to find longterm sustainable solutions to improvepatient care rather than to attempt quickfixes to hit performance targets’

A&E consultant lead, Homerton UniversityHospital NHS Foundation Trust

‘We often see our chief executive in theemergency department during periods ofsignificant change’

Nursing staff, Children’s A&E Department,Homerton University Hospital NHSFoundation Trust

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Key characteristic 2:The lead clinician workswith the trust executiveteam, primary care teamand users to championclinically led serviceredesign.

• A primary care trust (PCT) leadwho understands the pathwayis engaged in children’s serviceredesign, information sharingand including children and theirfamilies

• Regular meetings between thePCT children’s commissioner andlead clinician

• Clinical leaders engage with thelocal community to seek theviews of children and families

• Clinical leaders have a goal andmission for developing theservice.

Useful measures:

• Staff survey on leadershipbehaviours would be a goodindication to assess howengaged your executive teamis with your services. For helpwith developing this survey,see the HealthcareCommission’s National NHSstaff survey 2007 (see‘References’ section at the endof this document)

• Joint working betweenprimary and secondary care,for example, the number ofshared care pathwaysdeveloped to avoidinappropriate admissions

• Percentage of correcttransfers/referrals betweenprimary and secondary care,based on agreed criteria sothat more children and youngpeople are managed in anambulatory manner

• Measuring children’s andfamilies’ experience, forexample, by usingquestionnaires to gatherinformation from arepresentative sample of thecommunity will helporganisations provide aresponsive service.

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Key characteristic 3:Effective and safeemergency and urgentcare can be deliveredwithout on site inpatientbeds.

• Inpatient facilities arecentralised to a small numberof sites, coupled with thedevelopment of neighbouringambulatory units in other sites

• The availability of a critical massof trained professionals toprovide safe round the clockinpatient care on one site andappropriate cover for the otherambulatory site.

East and North HertfordshireNHS Trust runs two hospitalswith 24/7 accident andemergency services andinpatient facilities for children.

There was a duplication ofmedical and nursing staffcovering two separate facilities,with a small number of

admissions. There were notenough nurses or medical staffto provide safe and high qualityservice on both sites. The leadclinician worked with themanagement team, other staffand stakeholders in the localhealth economy and users of theservice, to provide all inpatientservices on one site and an

ambulatory paediatric unit onthe other site. This has resultedin a decreasing number ofadmissions and only a smallfraction of children who used tobe admitted to the QueenElizabeth site are transferred tothe Lister Hospital site (which isthe inpatient site).

Case studyEast and North Hertfordshire NHS Trust

In 2007 the service had its lowesttransfer for admission andovernight stay rate ever, despitethe increasing complexities ofthe medical and social issues

now encountered in paediatrics.

The clinical lead recommendsearly redeployment andadjustment of consultant job

plans to reflect the increasingconsultant led decision makingrequired when operating anambulatory unit.

1997 2007

Emergency medical paediatricadmissions per year

3000 900(700 ambulatory overnightadmissions plus 200 transferredto the inpatient ward).

Number of beds 44 inpatient beds 6 ambulatory beds22 inpatient beds

Useful measures:

• Number of transfers from anassessment unit to a ward tomonitor a reduction in numberof inappropriate admissions

• Changes in number ofinpatient beds utilised forchildren and young people

• Benchmarking performance onLOS using the national best25% performers (upper

quartile) as a measure - (1.86days, based on HES data06/07).

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Key characteristic 4:A fully integratedchildren’s service delivershigh quality and seamlesscare for children.

• One team of management andadministrative support acrossacute and communitypaediatrics

• Fully integrated and co-locatedteams (clinically, manageriallyand financially) encompassing,doctors, nurses, safeguardingstaff, school nurses, therapists,play specialists, health visitorsand community children’snursing teams

• Consultants work acrosscommunity and hospitalsettings providing continuityfor the family and avoidingfragmentation and duplicationof care

• One set of integrated medicalrecords.

Basingstoke is a fully integratedservice - clinically, managerially,financially and geographically.The hospital paediatric service,community service, children incare, safeguarding services,therapy services, school nursesand community children’s nursesare all co-located and managedas one service.

Every child has a namedconsultant and a community

children’s nurse. There is noartificial separation betweenservices provided for children inthe community and in thehospital, with the caresupported by a single set ofmedical records and the sameprofessionals working across thetraditional boundaries. This alsoreduces duplication ofmanagement systems andcreates a better flow ofinformation. This integrated

approach also cuts costs as fewerstaff are needed. The workingrelationship between teams isbetter as they have the greateropportunity to agree aconsensus approach overpriorities. In essence, thisapproach enables a range ofservices for children and youngpeople to be dealt with in amore co-ordinated way.

Case studyBasingstoke and North Hampshire NHS Foundation Trust

Useful measures:

• Percentage of services (acuteand community) that performagainst jointly agreedoperational frameworks(financial, managerial and

clinical) ensuring children andyoung people are managedefficiently and effectively

• Evidence of multi-agencycollaboration andimprovement action, for

example, joint funding andjoint development of servicesalong the pathways acrossprimary and secondary care.

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Key characteristic 5:Jointly developed childrenand young people’semergency and urgentcare clinical networks(spanning primary andsecondary care) provides aseamless high qualityservice.

• Clinical lead attends practice-based commissioning groupsand develops shared pathways,e.g. respiratory, UTI

• Clinical lead attends GPconsortium meeting monthly todesign pathways of care and toidentify services that needdeveloping.

An ambulatory paediatric servicewas developed for a populationof more than 54,000 childrenunder the age of 16 years. Thiswas done in an area of highdeprivation and need with amulticultural population and ahigh proportion of refugee andmigrant communities who arenot registered with a primaryhealthcare team. Previously, anaccident and emergencydepartment existed whichpredominately served teenagerswith trauma and minor injuries.But there was no formalpaediatric service and hence nopaediatric trained personnel onsite (informal support beingprovided by the neonatal teamfor true emergencies and advicebeing given from a

neighbouring children’shospital).

A children’s accident andemergency, children’s assessmentunit and an observation unithave been developed with alimit on length of stay of 24hours. There is a telephonehotline through which advice isprovided to the primary carestaff, and, if face-to-faceconsultation is needed, this isarranged in the daily urgentcare clinic.

The care is delivered by amultidisciplinary team withhands on care delivered byexperienced children’s nursesand consultants.

With 24 hour ambulatorysupport, transfer from Accidentand Emergency to otherpaediatric units fell from 8.4%(which is 405 transfers out of4814 attenders) attendees(which is 529 transfers out of atotal of 14,965). Activityincreased by 213%, and 94.9%of children are now totallymanaged in the ambulatoryservice without transfer.

High dependency support wasavailable prior to transfer forthose requiring it, and seniorclinical assessment facilitatedtransfer to a definitive unit ofcare was available wheresupraspecialist care wasrequired.

Case studyHomerton University Hospital NHS Foundation Trust

Useful measures:

• Percentage of GP enquires andpotential referrals managed bya telephone hotline by thepaediatric staff

• Number and percentage oftransfers from assessmentunit/observation unit to aninpatient ward to monitor areduction in the number ofinappropriate admissions

• Percentage of transfersachieved within two hours ofdecision to transfer from theambulatory unit to aninpatient ward on other sites.

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Key characteristic 6:Integrated informationprovision across a wholesystem facilitates patentcare and flow.

• There is real time provision ofclinical patient information forall teams involved

• A central information analystwithin children’s services,helping staff identify what theyneed, record and analyse dataon all aspects of the service.

There is a full time informationofficer based within thechildren’s services. The officerworks with the teams toencourage the use ofinformation and to educate staffon how to use data to informday to day service provision andlonger term commissioning ofservices. Additional support hasalso been provided to:

• influence casemix, volume andimpact of the workundertaken by the communitynursing team on preventingadmission and facilitatingearlier discharge for keygroups of children

• assist the play specialist teamin demonstrating their activitywithin the service

• help the physiotherapy andoccupational therapy teamsunderstand their wait timesand identify case load volumesacross the acute and thecommunity service

• assist the ambulatory unit bycollating and summarisingmore detailed clinicalinformation such as bloodtests and sweat tests.

This support has meant that theyare in a better position tounderstand their integratedservice, both from a volume anddemand perspective, as well asidentifying key trends such asreferrals and wait times.

Case studyBasingstoke & North Hampshire Foundation Trust

Useful measures:

• Percentage of staff usinginformation to understandtheir caseload and casemix andinform service planning, forexample assessing individualappraisals

• Measuring children and youngpeople’s and their families’experience, for example usingnational surveys

• Number of bed days saved as aresult of facilitated earlierdischarge, using performance

indicators such as bed daysoccupied, correlated withnumber of delayed discharges.

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Key characteristic 7:There is competentdecision making by seniorclinical staff.

• Appropriate staff have the skillsand experience to undertakecomprehensive assessments,initiate investigations andtreatment

• Education and training isregarded as an equal priorityamongst all otherresponsibilities

• There is a standardisedassessment process used by allprofessionals.

‘A child presenting with a rash could have either a self-limitingviral illness needing reassurance or meningococcal septicaemianeeding advanced life support and admission to a paediatricintensive care unit’

Dr Venkat Reddy, Consultant Paediatricianand National Clinical Lead, NHS Institute forInnovation and Improvement

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The emergency department atBasingstoke Hospital provides aprogramme of multidisciplinaryteaching and training sessionsled by the emergency medicineconsultant.

Once a month the session isdedicated to children’semergency and urgent care.This arrangement has resulted ina common understanding andimproved joint working amongthe professionals in thepaediatric and emergencydepartments and the transfer ofskills between the two.

A standard operating procedurefor paediatric critical care hasbeen agreed between theemergency physicians,paediatricians and anaesthetiststo ensure consistent care isprovided by the three specialtieswho are working together to acommon policy. This standardoperating procedure has beenratified by the regionalPaediatric Intensive Care Forumand been recommended toother hospitals in the area.

A key component to the successat Basingstoke has been themaintenance of advanced airwayskills by the emergency medicine

consultants. This has the addedadvantage of enablingprocedural sedation to beundertaken on children in theemergency department,resulting in fewer children whorequire suturing or fracturemanipulation having to beadmitted to inpatient beds,reducing costs and length ofstay. Several emergencymedicine registrars from otherregions have arrangedsecondments at Basingstoke inorder to acquire experience insafe paediatric proceduralsedation.

Case studyBasingstoke and North Hampshire NHS Foundation Trust

Useful measures:

• Percentage use of astandardised assessmentprocess that improves thequality of the assessmentprocess

• Percentage of staffdemonstrating relevantcompetencies throughappropriate assessment, forexample through individualstaff appraisals

• Evidence of joint workingbetween the paediatricdepartment and theemergency department, forexample joint meetings withcollective action plans

• The trend in the number andpercentage of children andyoung people referred fromthe emergency department tothe paediatric department

• Time to brief clinicalassessment (percentageachieved within 15 minutes)*

• Time to clinical decision madeby a competent professional(percentage achieved withintwo hours).

* ‘Services for Children in Emergency Departments’, April 2007, Report of the Intercollegiate Committee for Services for Children in Emergency Departments,p11, Section 5, no. 2http://www.rcpch.ac.uk/Health-Services/Emergency-Care

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Key characteristic 8:Recognising andresponding to concernsabout child protection isfundamental to anysystem that is set up todeal with children’s andyoung people emergencyand urgent care needs.

• An integrated safeguardingteam that works across primaryand secondary care and in alldepartments where childrenand young people are treated,ensuring a safe, effective andtimely response to any concernsabout safeguarding.

Approximately 25,000 childrenattend the Medway NHS TrustAccident and EmergencyDepartment. Following theVictoria Climbie Inquiry (LordLaming, HMSO, January 2003),the trust decided that a moreintegrated team consisting ofthe named nurse, paediatricliaison advisor and a childprotection co-ordinator, shouldbe co-located to work closelyand address the ongoing anddemanding safeguardingagenda.

The full time paediatric liaisonadvisor is managed by theprimary care trust. The post wasjointly funded by the MedwayPCT and Medway NHS Trust. Thenamed nurse, paediatric liaisonadvisor and child protection co-ordinator are based in a centralchild protection office. Co-location improvescommunication, facilitatesquicker access to medical recordsand ensures a more promptresponse to enquires. The teamhave improved databases onchild protection referrals andaudit child protection activity.

The trust has a safeguardingforum chaired by the namednurse. This is attended by theleads in paediatrics, maternity,school nursing, learningdisability teams, children’s homecare, the general manager andthe named doctors. Cases areshared where there are lessonsto be learned, there is discussionon working practices andinformation from localsafeguarding boards is cascaded.

Case studyThe Medway NHS Trust

Useful measures:

• Percentage of staff withappropriate level of childprotection training (95% ofstaff should be trained)

• Degree of compliance with aselection of recommendationsfrom the Laming enquiry* forhealthcare organisations.

* ‘Services for Children in Emergency Departments’, April 2007, Report of the Intercollegiate Committee for Services for Children in Emergency Departments p13,Section 9, no. 2http://www.rcpch.ac.uk/Health-Services/Emergency-Care

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5. Pathway specific characteristicsIntegrated urgent care centre

This section describes theintegration of processes betweenambulance services, out of hourscare, primary care, NHS Direct,child and adolescent mentalhealth services, social care,community children’s nursingteams and the acute trust.

Many systems have multipleaccess points for children andyoung people with acuteproblems. Each can causeconfusion. One access point forall urgent care needs, withassessment and streaming to themost appropriate service couldhelp avoid confusion. Theseoptions could include telephoneadvice or primary care attendance

(out of hours response or daytimeservice such as a walk-in centre),emergency care practitionerattendance, community nursingattendance, intermediate care,urgent access clinic appointmentsand paramedic attendance - withor without transfer to anintegrated emergency care centrefor more detailed assessment.

Key characteristic 9:Enhanced primary servicesfor children’s and youngpeoples urgent careprevent unnecessaryattendance at hospitalemergency departments.

• Advanced children’s nursepractitioners deliver care in adedicated children’s walk-incentre in primary care

• Joint development of referraland management pathwaybetween a walk-in centre andthe hospital

• A service level agreement(formal arrangement) betweena walk-in centre and thehospital for advice and training

• An advanced nurse practitionerin walk-in centres providessupervised practice and peersupport to practitioners in otherwalk-in centres across thestrategic health authority.

23

Smithdown Children’s NHS walk-incentre is the UK’s first (and only)NHS walk-in centre devotedspecifically to children. The centreis located approximately fourmiles from Liverpool city centreand is open Monday to Fridayfrom 8am to 8:30pm and 10am to4pm at weekends.

It serves a diverse, inner-citypopulation. Minor illness andinjury assessment andmanagement is provided by ateam of advanced paediatric nursepractitioners (APNPs) incollaboration with paediatricnurse practitioners (PNPs) andpractitioner’s assistants. There arex-ray facilities available Monday toFriday (with the diagnosisconfirmed by consultantradiologists) and access to off-sitediagnostics that includehaematology and microbiology.

Smithdown was reconfigured inApril 2006 to provide both minorillness and injury management.Key considerations in the serviceredesign were:

1. Education and training issues -seven nurses completed theMSc Advanced Paediatric Nurse

Practitioner programme inpaediatric ambulatory care andan additional five nursesundertook a short course inpaediatric minor illness

2. Formalisation of the links to thelocal children’s tertiary carehospital (achieved through aservice level agreement).

Attendances at Smithdown sincethe reconfiguration haveincreased 72% (8,462 children in2005/06 and 14,549 children in2006/07). In addition, 36% offamilies (n=2,949) state theywould have attended thechildren’s A&E department (orcalled 999) if the walk-in centrewas not there. Although there isno quantifiable data available toassess the impact on GPattendances, 48% of families(n=3,945) state they would havesought care from their GP for theirchild’s illness if the services atSmithdown were not available.

Minor illness completion ratescurrently exceed 85%. The impactof the reconfigured Smithdownservices on minor illness and injuryattendances in the children’s A&Edepartment is difficult to

ascertain. There has been(essentially) no increase in newA&E attendances since theredesign (60,851 children in2005/06 and 61,083 children in2006/07; an increase of 232children). This is despite thenational trend of a year on yearincrease in attendances to thedepartment. A telephone (follow-up) audit is currently in progressat Smithdown to further validatethe data.

(See Figures 4 & 5)

Interim feedback from Smithdownfamilies participating in this study(n=85) consistently rated the APNPconsultations as ‘excellent’ withregard to their overall satisfaction,and, more specifically, toindicators such as: the degree towhich the APNP involved theparent/carer in the child’s care;how well the APNP explainedtheir child’s health problem; theAPNP’s patience with questions orworries; the parent/carer’sunderstanding of and ability tocope with their child’s healthconcern (post-consultation) andparent/carer’s perceived ability tokeep their child healthy (post-consultation).

Case studySmithdown Walk-in Centre, Liverpool Primary Care Trust

6 ‘Evaluation of the Implementation of Advanced Paediatric Nurse Practitioner (APNP) Role in Ambulatory Paediatrics: Interim ReportYear 2’ Holborn, A. www.hopestreetcentre.com

In addition, the interim report6 concludes that there have been:

‘Positive patient outcomes from all of the APNP roles and there are many examples in the data whereAPNPs have added value to the patient episode and have successfully diagnosed complex problemsthrough clinical assessment.’

‘In addition, because of the holistic approach in the APNP role, patients have benefited from thewider care approach, for example APNPs can offer health education, advice and parental educationthat impacts positively on the child’s condition and wider well being.’

(Taken from interim report, Holborn, A. p. 43)

24

Figure 4: Smithdown Children’s NHS Walk-in Centre transfers

Total attendances = 8141 children1 April – 30 September 2007

Figure 5: Smithdown Children’s NHS Walk-in Centre Access Data

Visit intention: ‘What would you have done if Smithdown was closed?’1 April 2007 – 30 September 2007

Source: Liverpool PCT, Department of Information Management and Technology (October 2007)

Source: Liverpool PCT, Department of Information Management and Technology (October 2007)

25

* ‘Services for Children in Emergency Departments’, April 2007, Report of the Intercollegiate Committee for Services for Children in Emergency Departments p10,Section 3, no.9 http://www.rcpch.ac.uk/Health-Services/Emergency-Care

Useful measures:

• Percentage of correcttransfers/referrals betweenprimary and secondary carebased on agreed criteria sothat more children and youngpeople are managed in anambulatory manner

• Number of children and youngpeople deflected fromemergency department by

monitoring the trend ofchildren and young peopleattendances over a sufficientperiod of time

• The primary care team shouldhave systems in place tocollate attendance data fromdifferent urgent careproviders*. This can beaccessed by the commissionersfrom the different providers

• Measuring children’s andfamilies’ experience, forexample by usingquestionnaires to gatherinformation from arepresentative sample of thecommunity will helporganisations provide aresponsive service.

26

Medway Primary Care Trustassumed responsibility for out ofhours services after theintroduction of the new GPcontract. The PCT now providesboth a GP out of hours serviceand booked daytime admissionsinto same day treatment centres.One centre is located a fewmiles from the hospital, whereasthe other is located on site atthe acute hospital next to A&E.

These two centres are knownlocally as Medway On Call Care(MedOCC) and are managed bya common managerial, financialand clinical governanceframework. A multidisciplinaryteam consisting of GPs andnursing staff operates across thetwo sites. The same daytreatment centre and thedepartment staff havedeveloped good workingrelationships and support eachothers' caseload in and out ofhours.

Any child presenting at theaccident and emergencydepartment with symptoms ofminor illness, rather thanaccident or trauma, is triagedback to the same day treatmentcentre within 15 minutes in linewith an agreed exclusioncriteria. In 2006/07, MedOCCmanaged over 5,500 childrenreferred on this pathway,representing an actual saving tothe PCT of over £300,000 on theA&E attendance tariff. Thepathway also ensures that thesechildren are more appropriatelymanaged in a primary caresetting.

Details of all consultations aretransferred electronically to thepatient’s GP surgery thefollowing morning. MedOCCmonitors and providesbenchmarking data to the PCTdemonstrating the percentageof practice populations whichhave attended A&E rather than

their own surgery, or who havebeen managed within the out ofhours period. This helps informimprovements in local GPservices.

MedOCC has also recentlyadapted its call taking system toenable specific reporting, bypractice, of those patients whocontact the service, havingalready been in touch with theirown surgery but were unable tosecure an appointment, or weredissatisfied. Any unregisteredchildren are given help toregister with a GP.

Approximately 20% of A&Eattenders have been triagedback to the same day treatmentcentre.

Case studyMedway Primary Care Trust

Useful measures:

• Number of attendances forchildren and young people inemergency departments as apercentage of total registeredby GP practice

• Evidence of multi-agencycollaboration and

improvement action, forexample, joint funding andjoint development of servicesalong the pathways acrossprimary and secondary care

• Percentage of total populationof children and young peopleregistered with a GP

• Percentage of children andyoung people unable to securean urgent appointment withtheir GP practice. This data canbe accessed from thecommissioners of the service.

• A local information tool is usedby a PCT to identifyinappropriate users of A&E andto proactively prevent furtherattendances to the emergencydepartment.

• PCT lead tracks referral rates byGP and shares the data with allGPs which leads to a change inpractice.

• Same day treatment centre co-located with emergencydepartment deflectsapproximately 20% of childrenthrough an appointmentsystem.

27

Emergency care centre

An integrated front-of-houseemergency care centre reducesthe number of steps in thedelivery of care. This centreshould include primary care,secondary care, social care andchild and adolescent mentalhealth services.

There needs to be an assessmentprocess that includes appropriatediagnostics and definitivediagnosis. This would allowchildren to be streamed to theappropriate setting. The range ofalternatives available would be‘see and treat’, triage to primarycare, children’s emergencydepartment, paediatric

assessment unit or paediatricward. Some of these childrencould be discharged home withinput from a communitychildren’s nursing service. Thesealternatives could be collectivelyknown as the ‘transfer of careprocess’ since they are providedduring the transitional period ofaltered health.

Key characteristic 10:An integrated common front of house emergencyand urgent care facility provides seamless streamingof children and young people to the mostappropriate service.

Previously, there was an existingprimary care led unit anddedicated children’s accidentand emergency facility within anestablished busy emergencydepartment. In addition therewas an on site, 24 hourchildren’s unit which providedassessment, observation andshort stay capacity. Despite thisthere was a large number ofchildren presenting to the A&Edepartment for their primarycare needs. There was nointegrated emergency centre inthe area.

A purpose built A&Edepartment, with an integratedprimary urgent care centre fromwhich daytime and out of hoursprimary care services are

provided, was developed in2006. The main purpose was toensure that children wereappropriately assessed to receiveongoing care and managementfrom the best equipped clinicalteam. This follows the ‘rightchild, right place, rightpersonnel, right time’ principle.

A child presenting here istriaged by a children’s nurseeither to the primary urgentcare centre, or children’s A&E, orreferred to the children’sassessment unit. The criteria fortriage to primary care weredeveloped collaborativelybetween the primary urgentcare centre, the A&E departmentand the paediatric department.The pathway and flow of

children between these areas isconstantly monitored and as theexperience and capacity of thecentre continues to improve asmore and more children areassessed to receive care withinthis facility.

The following graph (Figure 6)shows there has been anincrease in the percentage ofchildren triaged to the primaryurgent care centre month bymonth and challenging targetsare set to increase the numberof children triaged back to thisfacility. There is also a slightdecrease in the number ofattendances in the emergencydepartment.

Case studyHomerton University Hospital NHS Foundation Trust

28

Figure 6: Percentage of children and young people triaged to the PUCC and the number of attendees tothe emergency department

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Useful measures:

• Number of dedicated cubicleor trolley spaces for childrenand young people per 5000annual children and youngpeople attendances in theemergency department*

• Percentage of complete andaccurate correct-on-assessmentstreaming (for example, thepercentage of children andyoung people re-directed fromemergency departments to theprimary urgent care centre)

• Time to brief clinicalassessment (percentageachieved within 15 minutes)*

• Time to clinical decision madeby a competent professional(percentage achieved withintwo hours)

• Percentage of clinical stafftrained in appropriate levels ofpaediatric life support*

• Evidence of joint workingbetween paediatricdepartment and theemergency department,

including a named emergencydepartment liaisonpaediatrician and jointmeetings with collective actionplans

• Measuring children’s andfamilies’ experience, forexample by usingquestionnaires to gatherinformation from arepresentative sample of thecommunity will helporganisations provide aresponsive service.

* ‘Services for Children in Emergency Departments’, April 2007, Report of the Intercollegiate Committee for Servicesfor Children in Emergency Departments, p10, Section 3, no. 3, p11, Section 5, no. 2, p11, Section 6, no.2.

http://www.rcpch.ac.uk/Health-Services/Emergency-Care

30

Key characteristic 11:Availability of advice whenever needed for primarycare professionals from senior medical and nursingstaff, reduces presentation of children and youngpeople to secondary care and also decreases thechances of admission after presenting through outof hours service.

In keeping with the ambulatorymodel of providing emergencyand urgent care for children, itwas recognised that an urgentcare clinic and a GP hotlineservice was required, so that theprimary care team could obtaindirect and immediate advicefrom the paediatric consultants.

There are daily consultant runurgent care clinics with bookedslots for children with urgenthealthcare needs. In addition,there is a hotline for the primarycare team so that they canobtain advice from thepaediatric consultant about the

management of children, theneed for referral; and the mostappropriate route of referral.This assists in the triage ofchildren to the most appropriateassessment route and allowsongoing care in the primary caresetting with senior paediatricsupport.

The Urgent care clinic is runfrom the main children’soutpatient department withinthe paediatric unit and is distinctfrom the primary urgent careclinic in A&E. On average,approximately 10 calls eachweek from GPs are received and

the hospital sees approximately80 patients each month in theurgent care clinic.

This approach provides the rightsupport for the primary careteam, giving them confidence toavoid unnecessary referrals outof hours to the A&E departmentas a senior opinion is readilyavailable the following day.

This has reduced the number ofchildren being referred to thechildren’s A&E department, thechildren’s assessment unit androutine children’s outpatients.

Case studyHomerton University Hospital NHS Foundation Trust

Useful measures:

• Percentage of GP enquires andpotential referrals managed bytelephone advice by thepaediatric staff

• Satisfaction survey of primarycare staff about the service

• Percentage of services (acuteand community) that performagainst jointly agreedoperational frameworks

(financial, managerial andclinical) ensuring children andyoung people are managedefficiently and effectively.

• Consultant led urgent care clinicevery morning with aconsultant manned GP hotline

• Senior review clinics(consultant and registrar level).

31

Key characteristic 12:The development ofinnovative roles designedto provide urgentassessment and treatment.

Paediatric emergency nursepractitioners (PENP) in theemergency department provideage specific care by staff whoare educated specifically in theassessment and management ofchildren, including painmanagement.

The role benefits children andyoung people as they can beseen and treated more quicklywith fewer professionalsinvolved in each care episodeand timely pain reliefadministered. The impact of therole in the emergency

department has reduced thewait time from three hours totwo hours and pain relief is nowgiven within approximately 10minutes. Previously it was a 45-minute wait.

Case studyEast and North Hertfordshire NHS Trust

Useful measures:

• Time to brief clinicalassessment (percentageachieved within 15 minutes)*

• Time to clinical decision madeby a competent professional(percentage achieved withintwo hours)

• Percentage of children andyoung people with a pain

score included in the initialassessment whereappropriate*

• Time taken from triage toreceiving pain relief

• Measuring children’s andfamilies’ experience, forexample by usingquestionnaires to gatherinformation from arepresentative sample of the

community will helporganisations provide aresponsive service

• Number and percentage oftransfers from assessmentunit/observation unit to aninpatient ward to monitor areduction in the number ofinappropriate admissions.

Key characteristic 13:Co-location of emergency department, children’saccident and emergency and children’s assessmentunits improves the efficiency of the pathway andenables skill sharing and joint working.

A children’s assessment unit islocated next door to thechildren’s accident andemergency department enablingvery close, integrated workingand shared learning betweenthese areas.

This approach maximises thenumber of the children that aredischarged back to the

community without beingadmitted to the children’s ward.This has resulted in significantlyimproved waiting times,appropriate pathways of carebeing followed and improvedpatient satisfaction. This servicehas no difficulty recruiting intonursing roles, to the point wheredemand has outstripped supply.

The clinical lead recommendsclose working practices betweenall specialities involved in thecare of the child who presentsthrough the emergencydepartment with not justmedical paediatrics, but specialtysurgery as well.

Case studyEast and North Hertfordshire NHS Trust

32

* ‘Services for Children in Emergency Departments’, April 2007, Report of the Intercollegiate Committee for Services for Children in Emergency Departments p11, Section5, no. 2, p11, Section 5, no. 4.

http://www.rcpch.ac.uk/Health-Services/Emergency-Care

33

Key characteristic 14:Ambulatory paediatric units without on-siteinpatient beds will only work effectively if thereare the facilities to transfer children to thenearest children’s ward.

This hospital trust manages twohospitals 12 miles apart and thechildren’s inpatients beds arelocated in one of these.

The trust employs the St. JohnParamedic Ambulance Service toprovide dedicated transferbetween the two units. Childrenand young people needing highdependency care areaccompanied by appropriatelycompetent nursing or medicalstaff. Children and young peoplewho need transfer to a tertiarypaediatric intensive care unit aretransferred by a central retrieval

team. There have been noadverse clinical incidents sincethe St. John Ambulance Servicebegan to transfer children andyoung people.

The ambulance technicians arepart of the clinical team and arebased at the paediatricassessment unit in one of thehospitals. They provide a clinicalservice when they are notinvolved in the transfer ofchildren and they operateMonday to Friday between 1pmand 7pm.

Their aim is to be able totransfer patients in a safe caringenvironment as speedily aspossible to anywhere that isdeemed necessary. This has builtpublic confidence in the localcommunity that there are quickand reliable arrangements inplace for the transfer of a smallnumber of children who mightpresent at one hospital but needto be transferred to the otherhospital site.

(see Figure 7)

Case studyEast and North Hertfordshire NHS Trust

• St. John Ambulance delivers anintegrated service with clinicalteams including transferbetween two units.

34

Figure 7: A graph showing the relatively small numbers of monthly transfers between the two sites in 2007

Useful measures:

• Number and percentage oftransfers from an ambulatoryunit to an inpatient facility tomonitor a reduction in thenumber of inappropriateadmissions

• Decreasing the length of timefrom decision to transfer toactual transfer

• Measuring children’s andfamilies’ experience, forexample by usingquestionnaires to gatherinformation from arepresentative sample of

the community will helporganisations provide aresponsive service

• Response times for thechildren and adult mentalhealth services (CAMHS), 24hours a day seven days aweek.

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35

The inpatient ward

All decisions to admit will have aprescribed case management planwith identifiable necessaryinvestigations, interventions anda monitoring process. This planwill include timelines for theinvestigations and interventionsto be delivered with an estimateddate and time of discharge andthe clinical criteria for dischargeidentified at the time ofadmission.

The majority of children can bemanaged without anyinvestigations if they are assessedearly by appropriately trainedpaediatric doctors and nurses. Ifinvestigations are needed theyshould be performed andinterpreted by staff who have theappropriate knowledge and skillsin dealing with children andyoung people. Case managementup to the time of dischargerequires daily multiple senior

reviews to discharge as soon as itis safe to do so. Early liaison withthe community children’s nursingteam will ensure early dischargeplans are in place to supportchildren and families in thecommunity.

Key characteristic 15:Senior competent staff ensure timely clinicalassessments and clinical decisions, with aprescribed case management plan.

Useful measures:

• Percentage of expecteddischarge date and time (EDD)set by the consultant at thetime of the clinical decision

• Percentage of EDDs delivered

• Audit the use of criteria-leddischarge

• Percentage of dischargesummaries followingemergency attendance

received by the primary careteam within 48 hrs

• Number of early facilitateddischarges with follow-onsupport from a communityteam

• Percentage of children andyoung people presenting forre-assessment followingdischarge home

• Measuring children’s andfamilies’ experience, for

example by usingquestionnaires to gatherinformation to form arepresentative sample of thecommunity will helporganisations provide aresponsive service

• Benchmarking performanceregarding length of stay andre-admission rate using thenational best 25% performers(upper quartile) as a standard -(1.86 days, based on HES data2006/07).

36

Useful measures:

• Multidisciplinary medicalrecords audit with peer review

• Evidence of multi-specialtycollaboration and

improvement action, forexample, the development ofservices along the pathway

• Reduction in number oferrors/near misses, forexample, drug errors

• Reduction in number ofserious adverse incidents.

Key characteristic 16:Senior nurse leaders focus on improving qualitystandards through a system of audits and weeklyreporting.

The director of nursing set upthe Nursing and MidwiferyAudit System (NMAS) in 2004.The clinical nurse lead inpaediatrics developed the audittool for the children’sassessment and inpatient area.The data is entered by the leadnurse onto an online system. Ata weekly forum all matrons,together with the head nursesand the director of nursingacknowledge achievements anddevelop action plans to addressexisting challenges.

Weekly audits of the followingtakes place trust wide: MRSACDIF (those admitted with, oracquired); bed days lost throughbed closures; wearing of correct

uniform; pressure sores; losthours through sickness; studyleave; maternity leave; carer’sleave and flexi bank hours used.In the children’s unit, they havedeveloped and implemented aspecific daily documentationaudit.

• Daily documentation audit inpaediatrics led by the seniornurse on duty covers:

•• baseline observationsdocumented within 30minutes and full nursingassessment documentedwithin two hours

•• care plans and Kardexentries are accuratelyrecorded and signed

•• TPR (temperature, pulse andrespiration) charts

•• fluid balance charts

•• discharge checklists.

The documentation audit hasled to improved record keepingand the senior nurse believes thegreatest impact has been on:

• individual nurses documentingtheir evaluation of care plansthroughout each span of dutyas an ongoing process

• individual nurses takingresponsibility to accuratelyrecord care delivery.

Case studyThe Medway NHS Trust

37

Key characteristic 17:Play specialists areintegrated with all aspectsof children’s services.

• Play specialists are recognised askey to providing a high qualityexperience within a childfriendly environment

• Play specialists are involved inacute and ambulatory careteam meetings

• Play specialists are on the bleepsystem for emergencies andsafeguarding examinations

• Highly visible play specialistteam improves the hospital-wide physical environment

• Play specialists provideextended outreach into otherareas i.e. personal, social andhealth education anddistraction boxes in differentareas

• Play specialists provide access toplay and preparation forhealthcare interventions.

The play specialist team hasbeen established for 15 yearsand has developed into a sevenday, 7.30am to 6pm, serviceproviding support whereverchildren are in the hospital.

There is a team of 10 of whichsix are qualified to an Edexcellevel 4, and all are qualified to aminimum diploma level in childcare. All members of the teamare trained to level 3 (thehighest level) in safeguardingchildren. They are key membersof the safeguarding team andare managed by the childprotection nurse lead.

The play specialists joinpaediatricians, health visitors,social workers and police in thechild protection clinics, both inthe community and in thehospital. In these clinics they useplay to explore concerns and areavailable to support each childas well as parents and carers.They saw 332 children andyoung people in the childprotection clinics betweenJanuary 2006 and December2007.

They operate a rotational system(planned six weeks ahead)working in the emergencydepartments, wards, clinics,

diagnostics and theatres. Theyprioritise their workload eachday, are integrated with theclinical teams and work closelywith nurses, physiotherapists,occupational therapists andpaediatricians.

The team are part of theHospital Art and Design Groupwhich has responsibilities toensure donated funds are usedto maintain the appropriateenvironment for children andyoung people.

Case studyDerby Children’s Hospital

38

Play specialists are part of themulti-disciplinary team whoseresponsibilities includeorganising daily play and artactivities in the playroom or atthe bedside; providing play toachieve developmental goals;helping children cope withanxieties and emotions andusing play to prepare childrenfor hospital procedure.

Through their play basedobservations they are able toprovide additional informationto support professionals inmaking clinical judgements.They also teach the value of playto other staff groups. The teamprovide a seven day service tothe children’s wards, paediatricassessment unit and thechildren’s A&E department with

additional cover to outpatients,theatre, diagnostics and daysurgery on appropriate days. Theteam also support families andsiblings.

All of the play specialists aresupported through mentorshipand monthly meetings with theteam manager.

Case studyEast and North Hertfordshire NHS Trust

Useful measures:

• Measuring children and youngpeople and their familiesexperience, paying particularattention to the physicalenvironment from a ‘child’sand/or ‘young person’s eye’

• Percentage of children andyoung people who spent timewith play specialists in allother non-paediatricenvironments (for example,emergency department)

• Percentage of children seeneach day by a play specialist.

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Key characteristic 18:Safeguarding children iseverybody’s business. Anyemergency and urgentcare pathway should havea system for safeguardingchildren embedded withinit.

• Safeguarding service hasadequate resources withnecessary administrativesupport to deliver a responsiveservice

• As part of the initial triage andassessment of children, a childprotection questionnaire iscompleted

• Liaison nurse identifies childrenat risk in emergencydepartment and uses ‘youth atrisk forms’ and informs schoolnurses

• Community liaison nurseexperienced in mental healthaudits attendances inemergency department,analyses trends and informs anetwork of agencies acrosshealth communities.

The trust identified the need fora paediatric liaison nurse role toaddress the complexity ofsafeguarding concerns and theother social needs of childrenand young people who wereattending A&E in increasingnumbers. The liaison nurse has ahighly visible presence withinthe A&E department as well aspaediatric and adult areas. Thisis highly valued by the staff.

The A&E department is nowidentifying more safeguardingissues and concerns, forexample, child trafficking,private fostering and femalegenital mutilation. There areincreasing numbers of childrenreferred to community servicesthat would have previously been

unidentified. There has been anincrease of 31% in referrals toeducational services for childrennot at school, and an increase of35% to social services.

A domestic violence policyensures appropriate referrals ofchildren living in homes wherethere is domestic violence. Thissystem now indicates to socialservices and school nurses ifthere are children in the homeof adult patients who have beenadmitted to A&E followingdomestic violence at home.

The paediatric liaison nurse andcommunity liaison health visitordeliver joint educational sessionson safeguarding issues for awide range of staff including

health visitors, school nurses,community children’s nurses andpublic health co-ordinators.

When the paediatric liaisonnurse noticed a trend ofincreasing numbers of childrenpresenting to A&E with burnsand scalds, she worked with thePCT public health team toidentify the reason. It wasdiscovered, following aninvestigation, that children wereusing empty oven cleanerbottles as water guns. A publichealth education campaign waslaunched which led to adramatic reduction in childrenpresenting with oven cleanerburns and scalds. (See Figure 8)

Case studyHomerton University Hospital NHS Foundation Trust

‘I feel more confidentdealing with child protectionand social issues since thepaediatric liaison nurse cameinto post.’

Children’s A&E nurse

‘The paediatric liai son nurseis very supportive to thedepartment and I like beingable to discuss concerns withyou.’

Paediatric registrar

Figure 8: Reduction of the numbers of children attending A&E with oven cleaner burns

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Key characteristic 19:Plans are in place todevelop one stop childprotection examinationcentre which includespolice and social services.

The East and NorthHertfordshire Child HealthServices Safeguarding Team(made up of designated nameddoctors and nurse and a trustexecutive representative) hassuccessfully bid for half a millionpounds through the ChildProtection Capital FundingScheme.

The team has put together asuccessful business case toconvert one of their wards,which is no longer needed, intoa state of the art integratedmultidisciplinary child protectionexamination suite. There arefacilities for social care andpolice to be based here andchildren and young people with

suspected physical and sexualabuse will be examined here.The centre is scheduled to beopened shortly.

Case studyEast and North Hertfordshire NHS Trust

Useful measures:

• Percentage of children andyoung people seen on thesame day for child protectionmedical examinations

• Percentage of staff dealingwith children and youngpeople with appropriate levelof child protection training(95% of staff should betrained)

• Evidence of multidisciplinaryand multi-agency collaborationand improvement action, forexample, joint initiatives asillustrated above.

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Transfer of care function

The transfer of care functionimplied within this documentincludes all community basedservices, including emergencycare practitioners, communitychildren’s nursing services, childand adolescent mental healthteams and social care teams.

The principle behind the conceptof transfer of care is therecognition that patients canrequire the service at any point intheir journey in order to preventunnecessary hospital admission orto shorten the length of stay inhospital. All services need to be

integrated and co-ordinatedacross the whole system, enablingthem to be responsive andaccessible.

Key characteristic 20:Community children’snursing teams are anessential part of theemergency and urgentcare pathway as theyprevent admissions,support care at home andfacilitate early discharge.

• Community nursing teamsfacilitate choices of wheretreatment can be received

• Community nursing teamselectronically capture andreport activity to understandthe trends and demands for theservice

• Community nursing teams work24 hours, seven days a week,with an identified named nursefor every child

• Community nursing teams canaccess a paediatric consultant atany time.

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At Derby Children’s Hospital the‘Kids In their Own Environment’(KITE) Nursing Team provides aseven day ‘Hospital at Home’service. The team offers a 24hour service for palliative careand for some children careduring the period of transitionbetween the hospital and home– for example the first night achild goes home on enteralnutrition.

The members of the team havea variety of qualifications andexperience, includingqualifications in communitychildren’s nursing andrespiratory management.Continuous professionaldevelopment is provided by linksto tertiary centres and byworking closely with colleaguesfrom other centres.

The team captures informationabout their visits and otheractivities which enables them todemonstrate changes in bothdemand and casemix. The bargraph on the next page (Figure9) shows the increases in visits tochildren and families, especially

for those with palliative careneeds (the trend in 2006/07indicates an increase in thenumber of children who havedied in the community as theirpreferred choice), as well as anincrease for those with complexhealth care needs and otherspecialist nursing needs. Thismodel of care supports familiesin caring for these children athome.

Case studyDerby Hospitals NHS Foundation Trust

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Figure 9: increases in visits to children and families, especially for those with palliative care needs

Useful measures:

• Number of communitychildren’s nurses per 100,000children and young peoplepopulation compared withother similar units.

• Number and casemix ofchildren and young peoplelooked after at home by thechildren’s community nursingteam

• Number of early facilitateddischarges with follow onsupport from a communityteam

• Measuring children’s andfamilies’ experience, forexample by usingquestionnaires to gatherinformation from arepresentative sample of thecommunity will helporganisations provide aresponsive service.

500

450

400

350

300

250

200

150

100

50

0

Number of visits

Palliative/Respite Other SpecialistNursing

Enteral Feeding Epilepsy

2003-2004 2004-2005 2005-2006

45

Delivery of high quality careachieves a wide range of benefits.Figure 10 shows that, bydelivering quality for children’semergency and urgent care, anumber of common benefits canbe realised. The benefits apply tothe following three dimensions:

6. Benefits

• Safe, high quality local care

• Prevention of unnecessary admissions

• Care in dedicated environments

• Cared for by staff trained in the care ofchildren and young people

• Support for families

• Early discharge

• Reduced school absence

• Community children’s nursing support

• Access to play facilities and staff

• Improved health outcomes

• Children and Young peopleinvolvement

• Increased satisfaction

• Decreased absence rates

• Sustainable workforce development

• Collaborative relationships acrossdepartments

• Joint working with education andsocial care

• Participation in servicetransformation

• Making a difference

• Reputation for safe and highquality care

• Access to appropriate educationand training

• Implementation of the Children’s NSF

• Achievement of the goals of ‘EveryChild Matters’

• Reduction in emergency secondary careattendances

• Reduction in number of ‘zero length ofstay’ admissions

• Decreased length of stay

• Decreased readmission rate

• Decreased mortality and morbidity rate

• Better value for money

• Reduced critical incidents

• CYP involvement

46

Optimal delivery of high qualityemergency and urgent care forchildren and young people is anachievable goal. Theopportunities for qualityimprovement in this area areimmense and include:

• improved outcomes for childrenand young people supported byclinical evidence

• increased ambulatory care andreduced use of inpatient beds.

Good quality care costs less thansub-optimal care as admissionrates, length of stay, readmissionrates and complication rates arereduced.

The contents of this report arebased on the Delivering Qualityand Value Team’s observations ofthe practices of NHS organisationsthat are judged to be deliveringhigh quality care and value formoney. While all of theseobservations have been testedthoroughly, it should berecognised that they may not bethe only way of delivering highquality care and value for money.

However, we believe that theywill give valuable guidance anddirection to those seeking thisgoal.

To improve services, organisationsshould utilise this guidance andtake the following steps:

1. Understand how yourorganisation performs whencompared with the keymeasures and benchmarkssuggested.

2. Generate a locally integratedprogramme for improvement.

3. Integrate the local changemanagement programme withthe health communityintegrated serviceimprovement plan and localdelivery plan.

While this report offerssuggestions to care providers andcommissioners on how they mightoptimise their own provision ofcare, it is, of course, intended tobe a first step on the journey toimprovement. It will be followedby practical tools to helporganisations make thoseimprovements happen locally.

In particular, the DeliveringQuality and Value Team expectsto produce the followingresources to support thechildren’s emergency and urgentcare pathway:

• A toolkit for providers abouthow to involve children andyoung people in all aspects ofplanning, delivering andreceiving feedback onemergency and urgent careservices

• A guide to help children andfamilies navigate theemergency and urgent carepathway.

We will develop, prototype andtest these products and toolsbased on what we have observedduring this project and what wehave learned from the peopleproviding the most innovativecare.

They are expected to be availableby the end of summer 2008.

7. Conclusion

47

8. Acknowledgements

We wish to thank everyone who has contributed their time and enabled us to carry out this work.Particular thanks go to the staff who took time out from their busy schedules to show us how they workand for all the information they shared with us. This includes the organisations we visited. They are:

Basingstoke and North Hampshire NHS Foundation TrustHampshire Primary Care TrustCity and Hackney NHS Teaching Primary Care TrustCroydon Primary Care TrustDerby Hospitals NHS TrustEast and North Hertfordshire Hospitals NHS TrustEast and North Hertfordshire Primary Care TrustHomerton University Hospital NHS Foundation TrustMayday Healthcare NHS TrustMedway Primary Care TrustSmithdown Children’s Walk-in Centre Liverpool, Liverpool Primary Care TrustThe Medway NHS Trust

We would also like to thank the following for their valued contributions:

Edward Wozniak, Paediatric Medical Adviser, Department of HealthFiona Smith, Adviser in Children’s and Young People’s Nursing, Royal College of NursingJonathan Smith, Chief Executive, Cheshire and Merseyside, Child Health Development ProgrammeRoyal College of General PractitionersRoyal College of Nursing Simon Lenton, Vice-President for Health Services, The Royal College of Paediatrics and Child Health Sheila Shribman, National Clinical Director for Children, Young People and Maternity, Department of HealthThe Royal College of Paediatrics and Child Health (RCPCH)

48

9. Further reading and references

‘Services for Children inEmergency Departments’ (April2007) Report of the IntercollegiateCommittee for Services forChildren in EmergencyDepartmenthttp://www.rcpch.ac.uk/Health-Services/Emergency-Care

‘Making It Better: for children andyoung people - clinical case forchange’ (2007) Department ofHealth, Shribman, S.http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_065036

‘A Guide to UnderstandingPathways and ImplementingNetworks’ (2006)The Royal College of Paediatricsand Child Healthhttp://www.rcpch.ac.uk/doc.aspx?id _Resource=1739 – Similar pagesCHECK THIS LINK

‘Modelling the Future: Aconsultation on the future ofchildren’s health services’ (2007)The Royal College of Paediatricsand Child Healthhttp://www.rcpch.ac.uk/Health-Services/ServiceReconfiguration/Modelling-the-Future

‘Our NHS Our Future - next stagereview interim report’ (2007)Department of Health, Darzi, A. http://www.ournhs.nhs.uk/2007/10/04/lord-darzi-launches-his-interim-report

‘Getting the right start: NationalService Framework for Children,Young People and MaternityServices: Standard for hospitalservices’, (April 2003), D.H.http://www.dh.gov.uk/en/Consultations/Closedconsultations/DH_4085150

‘Preparing the child health nurse– fit for the future’ (2007) Royal College of Nursinghttp://www.rcn.org.uk/__data/assets/pdf_file/0006/111696/Child_Health_Nurse_fit_for_the_future.pdf

‘The Victoria Climbie Inquiry’(2003) HMSO, Lord Laming, http://www.victoria-climbie-inquiry.org.uk/finreport/report.pdf

‘Nursing: Towards 2015’ (2007) Nursing and Midwifery Council http://www.nmc-uk.org/aFrameDisplay.aspx?DocumentID=3550&Keyword=

‘Improving services for children inhospital’ (2007) HealthcareCommission http://www.healthcarecommission.org.uk/_db/_documents/children_improving_services_Tagged.pdf

‘Delivering Quality and Value:Focus On: Short Stay EmergencyCare’ (2006) NHS Institute forInnovation and Improvement, http://www.institute.nhs.uk/images/documents/Quality_and_value/Focus_On/DVQ_path_shortstayPROOF_Nov.pdf

‘Evaluation of theImplementation of AdvancedPaediatric Nurse Practitioner(APNP) Role in AmbulatoryPaediatrics: Interim Report Year 2. Liverpool: Hope Street Centre,Holborn, A. www.hopestreetcentre.com

‘Getting it right for children andyoung people - a self-assessmenttool for practice nurses’ (2006)Royal College of Nursinghttp://www.rcn.org.uk/__data/assets/pdf_file/0008/78668/002777.pdf

‘National NHS staff survey’ (2007)Healthcare Commissionwww.healthcarecommission.org.uk/_db/_documents/National_NHS_staff_survey_2007_Summary_of_key_findings.pdf

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