Children & young people assessment service standards Summary report March 2012
Introduction Summary of the model of care, good practice and recommendations to sites in the East of England (Table 1) Next steps for Trusts Next steps for the region Comments regarding the visit Evaluation of the visits Summary
Thank you to the professionals, children, young people and families who have supported the development and implementation of the Assessment unit standards. Together we can continue to enhance our Assessment Services for Children, Young People and families across the East of England.
The East of England Strategic Network for Child Health and Wellbeing published a set of clinical standards for the delivery of safe, high quality care to children, young people and families in an Assessment unit setting, supported by a summary of ‘What children, young people and families want from Assessment services’. Both publications are available at www.eoe.nhs.uk/page.php?page_id=1144 and an interview regarding the standards can be viewed at: http://www.thisisreviewspace.com/gasstreet/item/share/3106/cc57f9ce0665069d5e6e3e49c82c5480 The standards build on previous work to assist in the development of ‘gold standard’ paediatric ambulatory care services directly supporting the delivery of the Quality Innovation Productivity and Prevention (QIPP) agenda. The development of these standards has included the review of current national, regional and local assessment unit standards and operational policies. Questionnaires were circulated and focus groups facilitated with experienced multidisciplinary staff from across the region that have led and managed children & young people’s assessment units; professionals have informed and challenged the standards as they have evolved and children, young people and families have also been engaged in their development. The standards have been tested by Assessment Unit teams and all comments/feedback to date have been incorporated and they have been given the support of the Royal College of Paediatricians and Child Health and the Association of Chief Children’s Nurses. The East of England Strategic Network for Child Health and Wellbeing commissioned the NHS Institute for Innovation and Improvement to offer organisations across the East of England support in adopting and achieving these standards. Organisations were asked to form a multi-disciplinary group to undertake a self assessment utilising the assessment service standard tool which then informed the discussions/presentations during a site visit by external professionals. Site visits took place between October to December 2011, by Dr Melanie Clements, National Clinical lead for Children and Young People’s Emergency and Urgent Care/Consultant Paediatrician and Kath Evans, Children and Young People’s Emergency and Urgent Care Programme lead at the NHS Institute for Innovation and Improvement. Visits were undertaken to seventeen acute Trusts within the region that deliver acute paediatric care to Children and Young People. The visits were also supported by various professionals from across the East of England region according to their availability, including Dr Chris Upton, Co-Chair of the Strategic Network for Child Health and Wellbeing in the East of England. The site visits included a diagnostic ‘walk of the patient journey’ to the Assessment Service, Emergency Department supported by informal discussions with clinical staff and users of the service, followed by a Whole System professionals meeting, involving Managers, Clinicians/Senior Nurses, AHPs/Play Specialists and Commissioners. A summary presentation by the local team of the results of their Self Assessment was shared at the Whole System professionals meeting, followed by feedback from the visiting team which led to action planning regarding next steps. A summary of visits, outlining the variety of models of care in place to provide emergency and urgent care across the region, along with areas of good practice for sharing and recommendations offered to each site can be seen in table 1. 2
Summary of Model of Assessment Service/Emergency Department (ED) provision, key findings & recommendations CYP Assessment Standards Visits across East of England Oct-Dec 2011 (table 1) Trust
1. Norfolk and Norwich University Hospital NHS Foundation trust
Model of Care: Assessment Service/ED
Elements to share
The Paediatric Assessment Unit is located next to paediatric inpatient ward with separate staffing. The Emergency Department is geographically separated from the Paediatric department by a considerable distance. There is a small separate area for Children attending the Emergency Department with limited opening hours and a limited number of paediatric nurses within the Emergency Department establishment. There are shared resuscitation facilities with an allocated paediatric resuscitation bay. Generally all children requiring assessment by the Paediatric team will be transferred to the Paediatric Assessment Unit, the exception being those requiring resuscitation/stabilisation. There are discussions in progress regarding co-location of ED & Assessment services, this would require estates intervention. Model of Care: Assessment Service/ED
Great team working & clinical leadership – multidisciplinary & multidirectorate, shared vision. Good understanding of all of the major agendas. Effective streaming of emergency, assessment, inpatient and elective/day care activity with allocated staffing.
Commissioning & clinical collaboration. Trust wide Children’s Board. Quality & audit programmes that have demonstrated enhanced patient care.
Review of the poor facilities and short opening times of the Children’s ED area. This currently results in children being cared for in the main ED environment without audiovisual separation to adult patients, also it presents safeguarding and security risks. Review the long distance in between ED and CAU, is there an alternative? Shared education & training opportunities with ED – continue to enhance relationships prior to co-location Make the patient voice/feedback more visible e.g. ‘You said...we did..’ displays Progress the Community Children’s Nursing (CCN) agenda Continue to develop links with GP Commissioners to influence & develop the wider Children & Young People’s (CYP) agenda
Model of Care: Assessment Service/ED
Elements to share
Establishment of a Children’s Board, chaired by an Executive lead for CYP ED facilities for CYP to be enhanced - vision by senior team, executive support needed to progress this Co-location of CYP ambulatory care services with ED Rotation of staff between ED & Paediatrics Engagement with primary care & OOHs GP services: implementation of high volume pathways Extension of engagement & participation of Children, Young People and families in service design and delivery e.g. ‘You said..we did’ display Visible presence of Consultant Paediatrician within the Assessment unit e.g. ward rounds Opportunities/considerations
3. Mid Essex
The Children’s Assessment Unit is located in a bay at the front part of paediatric ward.
Great senior clinical leadership, supported by the Executive team.
Role of Clinical facilitator: shared learning across departments.
Trust and Commissioners to look outwards to best practice nationally to reiterate direction of travel for
2. Southend University Hospital NHS Trust
The Children’s Assessment Unit is located next to the paediatric inpatient area. In the Emergency Department there is a small isolated waiting area, there is an identified ED Consultant with sub-specialty training in paediatric Emergency Medicine. There are significant numbers of ED staff with European Paediatric Life Support (EPLS) and a growing number of paediatric nurses within ED.
[Type a quote from the document or the summary of an interesting point. You can position the text box anywhere in the document. Observations Elements to share Use the Text Box Tools tab to A committed & enthusiastic senior Paediatric Audit data sheet, of attendance, change the formatting of the pull workforce assessment times – clarity regarding quote text box.] Progressive service, willing to think expectations/standards. differently Safety culture embedded e.g. Paediatric Early Warning System (PEWS), Recognition of the Sick child training. Documented patient pathways. Shift from GP referral unit to an ambulatory model of care now embedded.
Paediatric referral document Paediatrics metrics audit Excellent links with Paediatric Community Nursing team & Psychology. Good Play Specialist team High numbers of EPLS trained staff – in ED & Paediatrics Standardised patient information leaflets – could be shared with primary care
Hospital Services NHS Trust (Broomfield)
The Emergency Department is geographically separated from the Paediatric department. There is a separate Children’s Emergency department waiting and treatment area and a growing number of paediatric nurses in the Emergency department. There are shared resuscitation facilities with an allocated paediatric resuscitation bay. There is no ED Consultant with sub-specialty training in paediatric EM. Generally all children requiring assessment by the Paediatric team will be transferred to the Paediatric Assessment Unit, the exception being those requiring resuscitation/stabilisation. There are discussions in progress regarding co-location of ED & Assessment services within the new ED Environment.
Good Commissioning engagement. Clinical facilitator role with a HDU remit embedded. Vision, passion and commitment to progressing Children & Young People’s Services A culture that’s progressive & CYP focused. Culture of learning from incidents. Extended days for Consultants: covers peak periods of activity.
Monthly Paediatric Intermediate Life Support (PILS), monthly resuscitation scenarios. Children’s early warning tool/ pain scoring – embedded across the organisation. Work on Situation, Background, Assessment & Recommendation (SBAR) in progress. ‘Assessing Children’ document
Model of Care: Assessment Service/ED The Paediatric Observation area is geographically separate to ED and inpatient paediatric wards with limited opening hours. There is a separate CYP waiting and treatment area co-located with adult ED services. There are shared resuscitation facilities with an allocated paediatric resuscitation bay. Paediatricians and Paediatric Nurses work in ED as all GP referrals are assessed within the ED.
Observations Great leadership, committed to the development of ambulatory care. Excellent relationships between Paediatrics & ED Appropriately resourced paediatric nursing workforce in ED Shared vision: ED, Paediatrics & users of what should be developed Understanding of activity and patient flow - opportunity to extend to look at self/GP referral patterns
Elements to share Collaborative working between ED and ambulatory paediatric team Rapid Access Clinic arrangements Education and training opportunities relating to ambulatory care Well developed, embedded nurse rotation programme GP present front of house, CYP can be streamed to if appropriate.
4. Cambridge University Hospitals NHS Foundation Trust
service redesign Use newly established Children’s Board to ensure regular and consistent progress against this acute care pathway and future opportunities. Strengthen links with Primary Care – Primary Care are critical to further improvements Continued growth & development of CCN services Ongoing communication between PCT Children’s board & secondary care regarding specific challenges e.g. CED Harnessing and responding to the voice of CYP & families e.g. ‘You said...we did..’ Adults are currently being seen & managed within the children’s ED area to be ceased due to safeguarding concerns. There is currently no ED Consultant with sub-specialty training in paediatric EM, an appointment would secure a focus in addressing CYP ED challenges and lead a MDT group to review CED issues. Benchmark against Report of the Intercollegiate Committee for Services for Children in Emergency Departments (2007) Consider co-location of Assessment service: Senior decision making at the front door/care closer to home Within the Assessment service: Extension of reception/administrative support for peak periods of activity 5-9pm Opportunities/considerations Development of an overarching Trust wide Children’s Board with Executive lead for CYP Strategy for developing general paediatric services required i.e. staffing, environment. Working towards co-location of ED and Paediatric observation area 24/7 Assessment & ongoing observation of sick children out of hours – implementation of PEWS/similar Numbers of staff with EPLS to be expanded Opportunity to explore CCN service development Pathway work with primary care and Hinchingbrooke Play Specialist team to cross cover areas Make the patient voice visible ‘You said..we did’ board More uniform environment across paediatric areas e.g.
review of Ward D2’s environment Trust
Model of Care: Assessment Service/ED
Elements to share
Children’s Ambulatory care beds are located in a 4 bedded bay at front part of inpatient paediatric area providing elective and emergency care (2 for A&E & 2 for elective) There is small separate CYP ED area, managed by Paediatric nurses in ED which is open until 12 midnight. GP referrals attend via this route There are shared resuscitation facilities with an allocated paediatric resuscitation bay.
Great Senior Clinical Nursing leadership Articulated vision for development of a dedicated CAU co-located with ED services Well established Children’s Nursing team within ED CYP focused environment Generic hospital feedback boards
CYP feedback opportunities Presence of the High Dependency Unit (HDU) facilitator role Separate CYP ED area & nursing workforce Senior decision making front of house, Paediatricians in ED
Model of Care: Assessment Service/ED The Children’s Assessment Unit is located in a separate bay at the end of the paediatric ward. There is a small separate waiting and treatment area for CYP ED activity with Paediatric nurse. There are shared resuscitation facilities with an allocated paediatric resuscitation bay.
Observations Superb multi-professional leadership Excellent relationships between ED & Paediatrics A shared vision for progressing CYP services Knowledge of service -‘talked’ the operational policy/good data awareness Commitment to developing services for young people e.g. working with Termination of Pregnancy Unit (TOP) regarding implementation of ‘You’re welcome’ standards
Model of Care: Assessment Service/ED
Elements to share Trust wide Children’s Services meeting with executive support/Named Exec lead for Children Clinical Performance & governance scorecard Distraction competencies/trigger list for incidents Lead/identified role for ambulatory paediatrics Developing Nurse Practitioner role with acute paediatrics Commitment to driving forward nurse led discharge Implementation of productive ward within paediatrics Elements to share
Paediatrician lead for Ambulatory care (confirmed as Dr Zeidan 20/12/11) Identified ED Consultant lead for CYP care Review Medical workforce Establish a CYP ‘whole hospital’ group – e.g. CYP Board to address CYP issues across the directorates Review of CYP activity inc. ED/ambulatory activity Paediatric resuscitation training, continue to build MDT scenario training, establish Paediatric Intermediate Life Support (PILS) & invest in EPLS Develop an ambulatory care operational policy MDT visits to areas e.g. Wirral Extension of high volume pathways to primary care Optimise user feedback ‘You said..we did’ board Implementation of productive ward – transfer to Paediatric ED area. Opportunities/considerations Development of acute paediatric outreach services GP engagement work – targeting high referring practices/ongoing high volume pathway development Maintain the vision & commitment to achieving a colocated CED & Assessment/Observation area Extend Children’s Services Trust wide meeting to external stakeholders e.g. Commissioners, local GPs.
7. Luton and Dunstable Hospital NHS Foundation
The Children’s Assessment Unit is currently located on paediatric ward. A new build in ED has resulted in separate children’s waiting and treatment area – operational policy currently being confirmed.
Senior multi-professional leadership – committed to driving services forward. Children being seen and treated within main ED – no separation. Currently a busy assessment area, with
Paediatric Sepsis Pathway developed. Detailed annual report on assessment services Senior Nurse leadership: HDU facilitator, Practice facilitator & discharge co-
5. Princess Alexandra Hospital, Harlow
Trust 6. The Queen Elizabeth Hospital Kings Lynn NHS Trust
Opportunities/considerations Co-location of Assessment services with ED – work towards 24/7 service Increased numbers of Children’s Nurses within ED, presence of play specialist support within new colocated service
Paediatric nursing staff in ED is limited but is being reviewed. There are shared resuscitation facilities with an allocated paediatric resuscitation bay. Plans to co-locate the Assessment unit service with ED are in progress for implementation in the early part of 2012.
limited capacity. A newly developed CAU area colocated with ED has been built. Well developed medical establishment.
Model of Care: Assessment Service/ED
Elements to share
The Children’s Assessment Unit is co-located with the ward & elective day area. The Children’s ED, providing a separate waiting & treatment area is co-located with adult ED, the CYP waiting area is small with limited visibility. There are shared resuscitation facilities with an allocated paediatric resuscitation bay.
Integrated CYP Service Senior multi-disciplinary leadership: medical, nursing & managerial Board level support for CYP services: CEO, DN, MD Purpose built, child centred environment, staff involved in design process Well developed ambulatory philosophy of care Clarity regarding ‘flows’ of patients Well embedded process of receiving feedback from Children & families Shared vision for the future, including development of Consultant Ambulatory/ANP roles
Model of Care: Assessment Service/ED There is a combined CYP ED with waiting and treatment areas integrated with the Assessment service receiving GP referrals. There is a separate paediatric resuscitation bay with 2 trolley spaces within the CYD ED.
Observations Leadership across ED & Paediatrics Dedicated ED CYP Consultant working collaboratively with Ambulatory Paediatric Consultant A shared vision for how the service
Trust wide Paediatric Forum, Medical Director chairing, attendance by Director of Nursing. Well developed Play Specialist service 7 day a week Community Children’s Nursing Service Established Rapid Access Clinic Collaborative working with commissioning Regular GP/primary education sessions Commitment to developing the Advanced Nurse Practitioner role – consider sustainability is 1 post enough? Commitment to sending nursing staff on HDU education programmes Integrated Care Pathway: febrile neutropenia / asthma ‘Information to help you after the death of your child’ leaflet Well developed CYP focused major incident plan Elements to share Collaborative working between Paediatrics & ED Development of the Paediatric Emergency Nurse Practitioner role (PENP) Nurse led management protocols
8. Colchester University Hospitals NHS Foundation Trust
Trust 9. West Hertfordshire Hospitals NHS Trust
ordinator. Outcomes following implementation of the telemedicine project, Rapid Access team & walk in GP service. Whole system collaborative working – pathway development. Targeted work with GPs. Children’s Assessment Knowledge Examination Skills (CAKES) course designed & implemented.
CYP Whole hospital board with Exec leadership Establishment of a Consultant/GP ‘hotline’ Co-ordinated approach to Rapid Access Clinic/ward returns – could they go to day case area/OPD? A further piece of work on this would be useful Nurse Practitioner development/nurse led discharge for high volume conditions User engagement/feedback specifically regarding CAU services ‘You said..we did’ Continuation and development of CAKES course EPLS training for nursing staff Promotion of the availability of a confidential area for discussion/guidance on capacity Opportunities/considerations CYP ED facilities: small treatment area, limited observation of waiting area, small numbers of RN (child)/RSCN to care for 14,000 attendees per year Active engagement of a CYP data analyst in directorate meetings Growth of the external paediatric network: Primary care, Walk in Centre, Minor Injury units etc Review GP referral patterns to target high referring practices Review of other Trusts CYP dashboards to assist in local development Visit other sites that have experienced similar challenges/opportunities e.g. Brighton & their review of ED services for CYP Ongoing work regarding implementation of ‘You’re welcome’ standards
Opportunities/considerations Extension & development of the Paediatric Liaison group – Executive/Non Executive engagement within secondary care Links with local Strategic Commissioning Network to share CYP challenges
Trust 10. Bedford Hospital NHS Trust
There is a Consultant ED lead for children who spends all but 1 session per week support the CYP service. There is a Paediatric Consultant Ambulatory care lead supporting this service. There is a allocated Paediatric Nursing workforce with Paediatric Emergency Nurse Practitioners who see, treat and discharge children.
could develop A child centred, ED/Assessment environment Separate CYP Resuscitation area Capacity within ED is very limited, noisy/busy environment - is this appropriate for patients requiring assessment/observation? ‘Tired’ inpatient paediatric environment
Paediatric Nurse Rotational Programme, with clinical placements, safeguarding, management & development input. Implementation of productive programme within CYP ED/Assessment area Visible patient feedback demonstrating changes made Commitment to auditing use & ongoing development of the Paediatric Early Warning tool
Model of Care: Assessment Service/ED
Elements to share
The Assessment unit is within a designated bay and is co-located with inpatient paediatric ward. There is a small CYP ED waiting area & 1 CYP cubicle. There are shared resuscitation facilities with an allocated paediatric resuscitation bay.
Inpatient/CAU environment, light, bright & CYP/family focused Effective multi-professional leadership Children being care for within the main area of ED – exposure to adults limited separation facilities Commitment from the multidisciplinary team to progressing CYP services across the organisation. PEWs well embedded within Paediatrics and theatres Implementation of high volume pathways Commitment to delivering effective play specialist service across the organisation
Commitment to development of Paediatric Nurse Practitioner role (1 trained & 1 being trained) Implementation of SBAR across nursing & medical practice Project management support to address challenges areas Investment in the play specialist role Paediatric phlebotomist service Links with Luton & high volume pathway implementation Children’s Strategic group in place with external partners e.g. Commissioning, Community Children’s Nursing Services, Walk in Centre.
Coding challenges, involvement of coding/data analyst in directorate discussions Sustainability & development of the PENP workforce to assist in managing activity Review of the capacity within ED/Assessment service to meet activity demands – 83pt’s a day/20,000 attendances per annum, development of the co-located Short Stay Paediatric Assessment Unit (SSPAU) with CED Ongoing collaboration with Community Children’s Nursing Services to ensure effective use of services. Urgent attention to ratify Patient Group Directives for use within CED Nurse led discharge for CED Access to ELPS/APLS training for staff Development of Play Specialist Services to cover ED Whole system approach – public engagement regarding appropriate use of services Review opportunities to develop Rapid Access Clinics/GP to Consultant Paediatrician hotlines Targeted work regarding attendance of those infants less than 10 days old – engagement with midwifery & health visiting services. Opportunities/considerations Co-location of ED & CAU environment/workforce Paediatric team nursing & medical to attend ED resuscitation training scenarios Professional Leadership of RN (Child) /RSCN within ED to be reviewed Implementation of PEWs within ED Community Children’s Nursing input to ED/CAU, explore where these services best sit? Whole system work with Primary care: review of GP referral patterns – high & low referring practices Adoption of high volume pathways within primary care Circulation of the information leaflet regarding CAU services to GP practices Implementation of a ‘Choose well for your child’ resource Visibility of capturing feedback from Children, Young People & responding to comments – ‘You said…..we
Trust 11. Peterborough & Stamford Hospitals NHS Foundation Trust
Trust 12. Basildon & Thurrock University NHS Foundation Trust
Model of Care: Assessment Service/ED The Assessment unit is co-located with ward with limited opening hours There is a CYP ED waiting & treatment area which was not open. There are shared resuscitation facilities with an allocated paediatric resuscitation bay.
Observations Passionate multi-disciplinary leadership: Medical, Nursing & Management support Executive lead for CYP at board level Active named CYP GP Commissioner A light & bright CYP environment – staff involved in design process Close geographical location between ED & Paediatric services CYP ED environment – although not always open so CYP cared for in main ED area Effective streaming of elective & urgent/emergency activity Established Rapid Access Clinics
Elements to share Streaming of elective & urgent/emergency care activity Support of Paediatric Nurse Practitioner role & focus given regarding sustainability of the role Play Specialist services – demonstration of impact e.g. reduction in GA rates Focus on HDU care: environment & staff training Implementation of high volume pathways & consistent patient information Paediatric Pharmacist based on the ward Morbidity & Mortality monthly meeting Virtual tour of environment available on line
Model of Care: Assessment Service/ED
Elements to share
The Assessment unit is co-located with the Paediatric ward in a small 4-bedded bay area, with a waiting room across the corridor, at the front of the paediatric ward. Building is in progress and a much larger CED will be open in 2012 & there is potential for co-location of the Assessment unit from ward There are shared resuscitation facilities with an allocated paediatric resuscitation bay.
Committed & enthusiastic nursing & medical team A new CYP ED environment currently being built A busy ‘over’ occupied 4 bedded assessment unit Culture of prioritisation & recognition of the sick child Children’s Board with Executive lead within the Trust Links with the Commissioners via the ‘Clinical engagement group’
Role of the Clinical Educator with a HDU focus Competency based induction programme for junior doctors Play Specialist service – funded & well embedded within the culture of organisation Tracheostomy competency package Paediatricians assessing CYP in ED APLS provided with a Paediatric Nurse APLS instructor Staffing establishment for the Assessment service
did….’ ‘Lean’ professional leadership from a nursing perspective Consultant Paediatric workforce is also ‘Lean’ Regular staff briefings regarding strategic vision & progress (fortnightly operational meetings in place on the paediatric unit) Opportunities/considerations Establishment of a Trust wide CYP board Identified ED Consultant with a lead for CYP Shared training between ED & Paediatrics, triage/resuscitation scenario training Professional Leadership of RN (Child) /RSCN within ED Visit to Watford to see ED & Paediatrics working collaboratively Wide spread adoption of high volume pathways developed by Hospital Trust within primary care Community Children’s Nursing input for acute care support Implementation of a ‘Choose well for your child’ resource Visibility of capturing feedback from Children, Young People & responding to comments – ‘You said…..we did….’ Opening hours of assessment unit & impact of closing at 9.30pm, current cultural shift to inpatient care at night. Opportunities/considerations Co-location of CYP Assessment service with ED Increase of Consultant Paediatrician numbers to address reduction in middle grade trainees Introduction of twilight Consultant working Development of Advanced Nurse Practitioner role – ideal for Assessment service Nurse led discharge & PGDs could be extended Streaming of elective activity Ongoing work with Commissioners regarding Community Children’s Nursing Emergency Surgical services Non-malignant Haematology CYP engagement and feedback opportunities Update/modernisation of current inpatient facilities
Trust 13. West Suffolk Hospitals NHS Trust
Trust 14. Cambridge Community Services NHS Trust/ Hinchingbrooke
Health Care NHS Trust
Model of Care: Assessment Service/ED
Elements to share
The Assessment unit is located at the front of the Paediatric ward. Within ED there is a small waiting area which is not audibly separate to adults, this is one paediatric cubical and one RN (Child) Nurse within ED. There are shared resuscitation facilities with an allocated paediatric resuscitation bay.
Committed multi-disciplinary senior team: medical, nursing & management Well embedded ambulatory philosophy of care Use of CYP & family feedback in service delivery Separate Assessment area co-located with inpatient service Paediatric Nurse Practitioner role within Assessment service, commitment to further development of the role. Commitment to ‘whole system’ approach and quality improvement methodology Limited capacity in ED: Small CYP waiting area – CYP exposed to the noise of the main A&E waiting environment - 1 cubicle allocated to see CYP (14,000 CYP seen per annum) ED: ENPs see CYP over 3yrs with minor injuries (1 ENP will see all CYP) Observations Committed multi-disciplinary team leading CYP services 1 Registered children’s nurse in ED – co-ordinating education of ED staff Speciality doctor linking in with ED – one session per week Education of staff across ED & Paediatrics Light, bright, well organised CYP environment – implementation of productive ward Staff trained & have access to
Established Children’s board with Executive support Active Commissioner engagement in service provision & development Commitment to whole system working in addressing the QIPP agenda Medical Staff working patterns – Consultant evening cover during periods of peak activity Support of Nurse Practitioner role development Patient engagement
Model of Care: Assessment Service/ED The Assessment unit is located at the front of the inpatient paediatric ward in a 6 bedded area (there is a much better area at back of ward that they could locate to). The ED has a very small CYP waiting area which is within the main adult waiting area, the ED has one allocated cubicle for children and one RN (Child) Nurse. There are shared resuscitation facilities with an allocated paediatric resuscitation bay.
Elements to share Productive ward – patient status at a glance/confidentiality addressed Growth & development of the Continuing care team Young People accepted up to 18 years of age Multi-disciplinary resuscitation scenario training – including ambulance service ‘Pain’ passport Good at recognising success & developing staff Linking in with Minor injury units/Walk in
required Increase in isolation & cubicle facilities to reflect current activity Opportunities/considerations Review of nursing establishment within ED to reflect CYP activity (14,000 per annum) – currently 1 RN (Child) in ED Consider professional leadership for Children’s Nurses in ED Ensure ED Nursing staff have opportunities to gain competencies in assessment & management of the sick & injured child (RCN/RCPCH 2010) Implementation of monthly shared learning resuscitation training scenarios engaging ED, Paediatrics & Anaesthetics Review of ED environment for CYP Co-location of CYP Assessment service with ED Formalise nurse led discharge practice PGDs to be extended Streaming of elective activity – focus initially on phlebotomy service Implementation of ‘You’re welcome’ standards within one service initially e.g. TOP th Replace 8 consultant & 2 acute paediatrician posts Lean Senior Nursing structure: consider role of Matron & Lead Nurse with Trust wide responsibility for CYP activity Ongoing work with Commissioners regarding Community Children’s Nursing Opportunities/considerations Establish a CYP Strategy/operational group that brings together both organisations & stakeholders to ensure delivery of high quality care across organisations/departments – executive leadership Location of the CYP Assessment service – consider colocation with ED in future Operational nursing lead for CYP Assessment service Role of the play specialist – demonstration of impact e.g. K wire removal with distraction Consider streaming of elective activity Consider streaming of emergency & urgent care activity - clarity regarding GP hotlines/Rapid Access
Trust 15. .James Paget Hospital University Hospitals NHS Trust
Paediatric Intermediate Life Support (PILS)
Centre – important recognition of the CYP activity within these services Nurse led discharge policy
Model of Care: Assessment Service/ED
Elements to share
Clinics/Consultant presence during peak periods of activity Circulation of information regarding service to GPs for sharing with parents at point of referral Review of GP referral patterns/collaboration on education & training Implementation of NHS Institute high volume pathways/Choose well for your child Working with GP/Children’s Commissioners Development of Paediatric Nurse Practitioners Review of ED environment for CYP Emergency Nurse Practitioners could extend competencies to see children under 5yrs Extension of numbers of RN (Child) nurses within ED – rotation with Paediatrics Growth of acute Community Children’s Nursing Services Opportunities/considerations
The Assessment unit is located at the front of the inpatient paediatric ward. The separate CYP ED waiting & treatment area is supported by RN (Child) Nurses employed by ED & from rotational posts with Paediatrics. There are shared resuscitation facilities with an allocated paediatric resuscitation bay.
Superb multi-disciplinary leadership who are influential in ensuring CYP issues are high profile on the Trust agenda Focus on CYP & family needs across the organisation Great commissioning engagement, shared vision Separate Children Emergency care area Visible locally interpreted national guidance e.g. NICE Fever traffic light Child friendly beds
Integrated Child Health Service: Acute & community care Well developed CCN service, with specialist roles Locally developed Paediatric Advanced Nurse Practitioner role – 3 currently in post Robust HDU & resuscitation education: Local study days, PILS, EPLS Well embedded nurse rotational programme covering neonates, paediatrics, ED, Community & recovery Collaboration with Trust phlebotomy team who utilise paediatric area supported by play specialists Variety of methods to capture CYP & family feedback e.g. photo board, links with Youth Parliament Utilisation of young people requesting work experience to assist in benchmarking service against ‘You’re welcome’ standards Play specialist service to Emergency Department Routine Paediatric Nurse (from inpatient
Implementation of a Practice educator role Continued focus on the ambulatory philosophy of care Does the Assessment area have enough capacity? Is there an opportunity to expand? Challenges: Triage facilities/confidentiality of patient information. Streaming of elective activity? Extended outpatient environment could assist in supporting this streaming Wider engagement with external stakeholders e.g. GPs/Education Review of GP referrals, targeted work with high referring practices Implementation of high volume pathways across primary & secondary care Information to GPs to share with families at point of referral Wider community information e.g. ‘Choose well for your child’ NHS Institute Emergency & urgent Care lesson plan
Trust 16. Ipswich Hospital NHS Trust
Model of Care: Assessment Service/ED
The Assessment unit is located with the paediatric outpatient area, in a designated bay with cubicles. There is a purpose built CYP ED waiting & treatment area supported by RN (Child) Nurses employed by ED. There are shared resuscitation facilities with an allocated paediatric resuscitation bay.
A senior leadership team committed to progressing CYP services Fire fighting by paediatric staff…. Over stretched Paediatric Service A CYP focused ED Environment 1 CYP Resuscitation bay – often used for adult patients 12 CYP Nursing staff within ED No plan in place to address reduction in trainee numbers A busy small CYP assessment area providing emergency/urgent & paediatric elective care
area) attendance at resuscitations in ED for additional Paediatric Nursing support High level of visibility of Safeguarding Named Nurse Implementation of evening clinics: allergy, diabetes, constipation Monitoring of activity e.g. assessment/review times Elements to share Paediatric ED: physically separated from the adult area Well established ED nursing team - RN (Child) Senior Nurse leadership role – vital in coordinating CYP services across the organisation e.g. demonstrated low sickness levels Executive lead/support for CYP Clinical Pathway group which brings together all specialities who see children – this could also extend to external colleagues. All staff undertake Paediatric Intermediate Life Support (PILS)
Opportunities/considerations Increase in Paediatric Consultant workforce in line with Facing the Future guidance, RCPCH (2011) Identified Paediatric Consultant lead for ambulatory care Review of clinical environment – currently not fit for purpose (currently Consultant offices doubling as clinic rooms) Review of Consultant activity e.g. currently taking bloods in clinics Co-location of ED & Assessment Unit service – gold standard Identified ED Consultant for CYP Allocation of an emergency doctor to children’s ED area would assist in timely management of patients Streaming out of elective work from assessment area Review of opening hours of assessment service – consideration of value of twilight shift to support peak periods of activity ? Better way of managing fever at night, rather than admitting all CYP with fever Investment in a Practice Development role to bring together ED & Paediatrics Consideration of the value of the Nurse Practitioner role within the Assessment Unit service Implementation of a paediatric nurse rotational programme. Review of Coding e.g. HDU activity Medical input into referrals is junior at present Capturing of the user experience ‘You said.. we said’ Engagement of Ipswich in Whole System – clinical pathway reform & Commissioning Opportunity to roll out You’re welcome’ standards
Links with minor injuries unit – governance issues re: CYP Trust 17. East & North Hertfordshire NHS Trust
Model of Care: Assessment Service/ED
Elements to share
Assessment unit co-located with Children’s Emergency department (ED) at Lister hospital. Service delivered by Paediatric Nurses, ED medical staff and Paediatricians. Integrated community services including Community Children’s Nurses and Community Paediatricians within this service. Services at QE11 provide, Outpatient services, Day Surgery and minor injury service.
Successful reconfiguration of Children’s Services – congratulations to the team Committed team with a vision for the future Streamlined, Emergency, Elective and inpatient services Investment in training 6 Paediatric Nurses who have an Emergency Nurse Practitioner qualification Children requiring OPD services are seen alongside adults in an adult focused environment Inpatient environment: dated, tired and cramped Limited capacity within the Children’s ED & Assessment unit area Very limited Community Children’s Nursing capacity: focused currently on specialist roles
Successful reconfiguration: a case study write up would be valuable for other sites to benefit from your approach Well developed ambulatory model of care Play Specialist service that is supported by volunteers – many have been there for years
Effective utilisation of Paediatric Nurses with Emergency Nurse Practitioner skills Addressing medical staffing rotas: investment in Consultant body to ensure sustainable solutions for the future Review of CCN activity and impact re: admission avoidance, investment in service development Engagement of CYP & families in service design & delivery e.g. ‘You said ..we did’ Benchmarking services against ‘You’re welcome standards – build on transition work – explore work in Oxford, Walsall & links with Transition Nurse in Hertfordshire Review OPD environment, consider safeguarding Visits to other areas e.g. Watford, co-located Paediatric resuscitation area with Children’s ED & Assessment service Whole system working: engagement with primary care, Health Visiting services, local Children’s Centres e.g. running advice/guidance session for families in the community in collaboration with GPs/Health Visiting. Develop and implement high volume pathways across primary and secondary care supported by agreed consistent patient information. ‘Choose well for your child’ Identify the Executive lead for Children within the Trust. Is there a ‘Whole system’ children’s board that would bring together internal & external partners. Invite Children’s Lead from Clinical Commissioning Group.
Next Steps for Trusts There are a number of overarching themes that Trust’s can action locally Ensure Organisational Children & young People’s Boards with executive leadership (as recommended by the NSF, 2003) are fit for purpose to address CYP issues across the organisation and are open to external organisations e.g. commissioners, local GPs, Minor Illness/Walk in Centres etc. Review Emergency Department Services, ensuring these departments have an adequate workforce & environment to meet 25% of activity relating to Children & Young People utilising the Report of the Intercollegiate Committee for Services for Children in Emergency Departments (2007). Ensure ED Nursing staff have opportunities to gain competencies in assessment & management of the sick & injured child (RCN/RCPCH 2010)
Watford has a two bedded paediatric resuscitation bay, co-located with the Children’s ED waiting & treatment/Observation area, the Children’s ED/Assessment Service is led by an ED Consultant, Paediatrician & Senior Paediatric Emergency Nurse Practitioners.
Consider streaming out of elective activity from the Emergency/Urgent care assessment activity to manage activity in a time and effective manner. Peterborough have streamed all elective activity into a nurse lead procedures area in the Paediatric Outpatient area, allowing staff to focus on either elective or emergency care, this has reduced length of stay and enhances the experiences of children, young people and their families
Benchmark services against ‘You’re welcome’ Department of Health standards http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_126813 to ensure services meet the specific needs of young people. Beth Shannon, Lead Nurse for Paediatrics at The Queen Elizabeth Hospital Kings Lynn NHS Trust is taking a pragmatic approach to achieving the ‘You’re welcome standards’. ‘We’re focusing our energies on supporting the Termination of Pregnancy unit (TOP) to achieve these standards, as they see significant numbers of young people’ Dr Mark Dyke, Associate Medical Director for Children at the Norfolk and Norwich University Hospital NHS Foundation Trust, shared that under the auspices of the Children’s Board they set up a working group for adolescents and young adults last year. It has resulted in the creation of a dedicated unit of inpatient beds for 16-21 year-olds (up to 24 for some conditions/circumstances), which opened in January 2012. They have also sponsored a Pathway for Transitional Arrangements between Children’s and Adult services. Take a ‘Whole system’ approach (utilising the NHS Institute’s resources in this area) to reviewing CYP Emergency and Urgent care, engaging with GP Commissioners/primary care is vital in undertaking activities to keep care closer to home. The team at Luton have been working with the NHS Institute for Innovation and Improvement since 2008 and are committed to working across the whole health and social care system to ensure high quality consistent care for the local population, this has included the development of six high volume pathways for CYP.
Further information can be found at: http://www.institute.nhs.uk/quality_and_value/high_volume_care/focus _on%3a_emergency_and_urgent_care_pathway.html
Continue to progress the development of Acute Community Children’s Nursing Services, further guidance is available at: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_124898
Provide high quality information for users regarding CYP services, e.g. ensuring GPs have information leaflets to share with families at point of referral to reduce anxiety and clarify that the referral is for assessment, not always admission.
In Basildon and Thurrock they had a bright colourful poster display about their Assessment Service that provided information for Children, Young People and families.
Teams highlighted throughout the visits that they had developed information about the Assessment service for families, but not all teams had shared this with GPs to distribute at point of referral
Enhance the visibility of listening and responding to the feedback of Children, young people & families In Watford poster displays were visible to children, young people and families demonstrating what had been done as a result of their feedback.
Review the Emergency Nurse Practitioner (ENP) role – is it possible for ENP’s to extend skills to see and treat children of all ages?
Emergency Nurse Practitioners are often very experienced in the management of minor injury; however there is significant variation across the region relating to the age of children they will assess and see. Development of a specific education programme supported by ED and Paediatrics could assist in enhancing their competencies regarding the assessment and management of children.
Demonstrate the impact of Play Specialists in enhancing quality, reducing length of stay and avoiding general anaesthetics/sedation.
In Basildon and Thurrock a prompt on the treatment room door ensures play specialists are utilised for distraction.
Next steps for the region There are also a number of themes that may benefit from a regional approach these include : Review of the academic education provision to develop Paediatric Nurse Practitioners Review of the Emergency Nurse Practitioner Education Programme and applicability and availability to Paediatric Nurses Review of CYP High dependency training (HDU); compare use of HDU facilitators ‘in-house’ versus Higher Education Institute (HEI) HDU Courses. Take forward discussions regarding transport service for CYP High Dependency retrievals via critical care network. Meet with East of England Ambulance service regarding education of staff and transport equipment for children Review and test effective models of GP feedback regarding CYP referrals to secondary care.
General comments regarding CAU Visits received via email I really enjoyed the process even though it was extra work! It is really good that there is a renewed focus on CAU which for a while has maybe taken a back seat to all the specialities. Jill Wakely, Senior Children’s Nurse, Norfolk and Norwich University Hospitals NHS Foundation Trust
Thank you for a very useful visit! We will devise an action plan and update you on the progress in due course. Peter Heinz, Consultant Paediatrician, Addenbrookes It was really a useful day for us to see where we need to go forward Debbie Twist, Head of Children’s Services, Princess Alexandra Hospital, Harlow
Thank you very much for the useful feedback about our department during your visit in Basildon. This really installed some fresh hope in all of us, particularly after recent criticism from CQC. I hope we can make the proposed changes with active help from higher management, with thanks, Sam Mukherjee, Consultant Paediatrician, Basildon & Thurrock University Hospital NHS FT
Thank you for your time and your really helpful visit and of course your positive feedback, that is always really good to get, we all really enjoyed your visit. Carol Newman, Lead Nurse Children and Young People, Mid Essex Hospital Services
Thank you for yesterday’s visit and feedback. We do appreciate the time and effort you have put into developing these standards and organising the visits etc. They have clearly helped us focus on our needs, priorities, gaps etc. We will be continuing to look at how we can improve our service with the added benefit of having these standards as a yardstick. Archana Soman, Consultant Paediatrician, Norfolk and Norwich University Hospitals NHS Foundation Trust
This feedback is very helpful and will be used to inform our local event in January. I really hope and expect us to progress improvements across our paediatric patient pathways as a consequence of this event and the plans that will no doubt come out of that. Joe Harrison, CEO, Bedford
Thanks for your very helpful guidance yesterday and the useful suggestions for improving links between the primary-secondary care interface. Dr Maria Karretti, General Practitioner, Gorleston Medical Centre
It was a great visit – the staff felt very supported and that it was a facilitative visit – in fact they reported today at the Children’s Directorate meeting that they felt reenergised by the visit and were happy to start looking at their gaps and areas for development. So thank you very much to all of you for your very important and valued input to this work. Siân Brand, Maternity, Neonate and Children & Young Peoples' Services Commissioner, NHS Mid Essex Thank you so much for such quick feedback - a really useful visit. Everybody should be rightly proud of the achievements to date and more improvements on the horizon. We will feedback to our executive team and hope to push forward the co-location of PAU The new QoF is an opportunity to create some local action. Dr Beryl Adler Consultant Paediatrician Divisional Director Women and Children's Services, Luton and Dunstable NHS Foundation Trust
Thank you very much for a very positive report and for highlighting areas where we can continue our improvement/development journey. Patricia Wright, Chief Executive, The Queen Elizabeth Hospital King's Lynn NHS Foundation Trust
Thanks you for coming to visit us and thank you for giving us feedback. The Ladies in my Play Team were so pleased that we had some positive feedback; this sometimes gets forgotten in the work environment. One of the outcomes from your visit is that Yvonne (senior Play specialist) has now done a work ethic for our team, It just goes to show how something like your visit has evoked enthusiasm. Thanks once again for your positive feed back, Jackie Keeble, Play and Activities Coordinator Southend Hospital It was great to meet you and spend the afternoon with your colleagues thinking about our vision for CED at Watford last week. We appreciate your positive feedback and the opportunity to be part of this exercise. We would be very keen to attend an event and would appreciate the earliest warning to organise a Watford contingent to attend. Good luck with your future visits, Thank you, Vimal. It was good to see you again. I, too, look forward to working on these issues locally with you and the commissioning team. In the meantime we will endeavour to set our case to the Trust. Dr Ashley Reece, Consultant Paediatrician, Watford General Hospital
“Can I just say this is the most positive meeting I have been to for sometime and I go to lots of meetings.” Peter Franzen, Interim Chair, James Paget
The review of the standards has been very useful and will go a considerable way to supporting the PAU team and its subsequent move to ED Tanith Ellis, General Manager, Children’s Services, Luton & Dunstable NHS Foundation Trust
It has been a really useful visit for us as well as it has really helped us to focus and think of the ways to move forward. We look forward to the spring event to catch up with all others. Birgit Van Meijgaarden, Clinical Director, Basildon & Thurrock
Thanks for your visit and feedback to the Paediatric Assessment Unit at Peterborough Hospital. Dr Afraa Al-Sabbagh, Consultant Paediatrician, Peterborough and Stamford Hospitals NHS Foundation Trust
An evaluation form was circulated following the visits and the following feedback was received: What (if any) benefits have the Standards offered? Focused us to re look at our systems and review An opportunity to critically appraise the service and benchmark. The standards have given us measurable standards from which to measure our practice. They have given us a formal comparison of what is going on across the network They have given the senior team a defined purpose to get together and review guidelines and Practice They have given us ideas for service improvements They have given us focus and clarity in achievable goals They have been an opportunity for reflection They have held up a mirror to the service helping us to recognise and prioritise our opportunities for improvement. What (if any) benefit did the peer visit offer? Shared working, ideas everyone wanting to share best practise A supportive forum in which to discuss current service provision and hear about other practices and services within the region (and wider area). A chance to engage the executive team and commissioners - and raise the profile of paediatrics on their agenda. It gave us a specific date to achieve goals It gave us the opportunity to feel pride for hard work and good practice It made us look at our service through someone else’s eyes It was an opportunity to take protected time to reflect on the service and the direction of travel. It will be helpful to share the experience of our peers going forward. Have you been able to make any changes as a result of your initial benchmarking or feedback from the visiting team? Yes now have contact with children’s GP commissioner and meetings set up to work together This is work in progress but we are hopeful that the necessary people have listened to us and the visiting team and recognise the issues. Yes prior to the visit and after and will be ongoing Consultants attending resuscitation training in E/D 20
Changed Strategic vision in collaboration with internal stakeholders.
Can you offer any recommendations regarding the wording/format of the standards? No x 2 A few areas we interpreted differently by different people Any other comments/feedback would be appreciated. I really enjoyed the process and would be willing to take part again. Thank you Just to reiterate that the process has been useful and, maximally so because it was performed in such a supportive way, thank you. I was really happy to be involved in the process and I think it would be valuable to for you to come back to us at a later date and see how we are getting on with the recommendations and opportunities for service improvement. General comments/feedback Having done none of the preparation work, I think this has been a very constructive experience. For the team on the ground there was a degree of anxiety, especially with the background uncertainty of the acute services review. It was a directive that made us look more carefully at what we do and how we do it. As a result, we have pulled together a lot of good work that was already happening to a more visible and demonstrable level. It has also given us clear pointers to take back to the Trust. The immediate feedback on the day was great and Mel and yourself handled the process very sympathetically. Thank you Dr Alison Sansome, Consultant Community Paediatrician and Clinical Director, Cambridge Community Services, Community Child Health I would echo Alison’s comments and thank everyone for all the work that went into the preparation for the visit. There was a lot of uncertainty about what was expected on the day however I personally enjoyed the experience and the constructive pointers to develop our service for CYP for the future. I would like to share this with Hinchingbrooke NHS trust with everyone’s permission. Thank you to your team who were very positive. Christine Luckham, Holly ward manager, Children’s unit, Hinchingbrooke Hospital Thank you for your supportive comments and the suggestions. It was hard work but definitely worth it. All the best and look forward to working with you in the future. Dr Nik Johnson, Consultant Paediatrician, Hinchingbrooke Hospital The preparation for this visit also helped our unit to focus on strengthening some of our data capturing and policies and procedures. I found the visit very good. It was open and honest visit and felt as supportive. Dr Birgit Van Meijgaarden, Clinical Lead, Basildon and Thurrock. 21
Conclusion The development and implementation of these co-produced standards, with engagement from professionals, children, young people and families has provided us with a resource to assist the region in the continuing journey to providing gold standard CYP services. As a result of this programme of visits, we now have an overview of how Trusts are delivering services against the set of agreed standards for Children and Young Peopleâ€™s Assessment Services. Ideas for ongoing service enhancement have been shared and an event in March 2012 will develop this further as professionals from across the region are invited to share best practice. We look forward to ongoing collaboration in Changing Child Health and Wellbeing together.
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