Children’s Services Handbook
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INTRODUCTION
Welcome to the Children’s Department.
The is so much to learn when joining a new team, and we trust this Handbook will be helpful.
The Handbook aims to cover the more administrative side of being a clinician in Paediatrics and Neonatology at this Trust, and the Clinical Guidelines and Policies are available separately
The handbook has been developed with the help of those who have worked here before you and needs to evolve. So, if you think that something helpful is missing, or incorrect, just let us know by emailing martyn.rees@nhs.net/Srinivas.parepalli@nhs.net.
The COVID-19 Pandemic has left a lasting impact upon our service, and there will inevitably be further challenges and changes. The contents of this Handbook may therefore be superseded by new Trust and National policies. To access the latest Trust information please click on the below links: (only available when using a Trust PC)
o http://intranet.sath.nhs.uk/coronavirus/
o http://intranet.sath.nhs.uk/paediatrics/COVID -19_Paediatrics.asp
MEET THE TEAM
CONSULTANTS
Dr Alison Belfitt
Dre Jennifer Brindley
SPECIAL CLINICAL INTERESTS
Neonatology. Palliative Care
Neonatology
Dr Richard Brough Rheumatology
Dr Andrew Cowley
Dr Patricia Cowley
Dr Sanjeev Deshpande
Dr Santwana Dwivedi
Dr Rupert Ellis
Dr Sapthagiri Gantasala
Oncology & Haematology
Diabetes & Neonatology
Neonatology & Metabolic Disease
Oncology & Haematology
Epilepsy
Gastroenterology
Dr Manish Gupta Nephrology
Dr Kathryn McCrea
Dr Sourabh Mukhopadyay
Endocrinology and Diabetes
Neurology and Epilepsy
Dr Susan Muniu Diabetes
Dr Srini Parepalli
Dr Tabitha Parsons
Epilepsy & CAMHS Link
Oncology & Haematology
Dr Sagarika Ray Neonatology
Dr Martyn Rees
Dr Rajesh Sakremath
Dr Kumar Sethuraman
Dr Nick Vrahimis
Dr Shoaib Iqbal
Dr Chinedu
Respiratory & Cystic Fibrosis
Endocrinology & Diabetes
Respiratory & Cystic Fibrosis and Allergy
Cardiology
Cardiology
CAU/HDU
ASSOCIATE SPECIALISTS/SASGs ADVANCED CLINICAL PROACTITIONERS (PAEDIATRIC)
Dr Sohail Ahmad
Dr J Babu
Dr Promise Monday
Dr Abdul Hamad
MIDDLE & JUNIOR TIERS
Amy Clarkson
Tracey Garrett
Rebecca Dickinson
Sarah Meehan
Rachel Hotchkiss
Jo Pugh Beckie Nock
Junior tier Paediatrics GPVTS & Paediatric ST trainees, FY1 and FY2 trainees
Advanced Clinical Practitioners in Paediatrics
Junior Tier Neonates Paediatric ST trainees and FY2 trainee
Advanced Clinical Practitioners in Neonatology
Middle Tier ST4+ trainees in General Paediatrics, Neonatology & Community
Associate Specialists
Separate daytime rota, joint for out-of-hours CLICK HERE TO RETURN TO CONTENTS
MANAGERS
Clinical Director for Paediatrics
Paediatrics Governance Lead
Business Director for Neonatology
College Tutor
Women & Children’s Care Group Medical Director
Divisional Director of Nursing- Women and
Children’s
Children’s Ward Manager
Paediatric Matron
Neonatal Ward Manager
Neonatal Matron
Safeguarding Lead Clinician
Child Protection Lead Nurse
Paediatric Audit Lead
Paediatric Guidelines Lead
Critically Ill & Injured Child Lead
EDUCATION & TRAINING
Dr Gantasala
Dr Srini Parepalli
Dr Patricia Cowley
Dr Rupert Ellis/Dr Alison Belfitt
Mr Martyn Underwood
Julie Plant
Jenny Probert, Jennie Errington, and Charlotte Davies
Rachel Bennett
Sian Duckett
Vacant
Dr Kumar Sethuraman
Teresa Tanner
Dr Kumar Sethuraman
Rachel Hotchkiss, ACPP
Dr Susan Muniu
EDUCATIONAL & CLINICAL SUPERVISORS AND APPRAISALS
TRAINEE
• All trainees are allocated a Consultant Supervisor by the College Tutor
• Trainees are responsible for arranging their first meeting with their supervisor within the first 2 weeks of start of post and must contact the Consultant's Secretary to arrange this meeting
• Frequency (minimum) of progress review meetings:
o 6-month post - start, mid and end post interview
o 4-month post - start and end post interview, with an informal mid-post discussion
NON- TRAINING GRADES
• A Consultant Supervisor is allocated at start of post by the Paediatric Clinical Director
• Annual appraisal is mandatory, using the Trust’s Premier IT Revalidation e-Portfolio (PReP) system – accessed via https://sath.medicalrevalidation.com/
• For information on the process of appraisal:
o Access the Medical Directors site on the Intranet
o Discuss with Clinical Director or appointed Consultant Supervisor
o Refer to GMC guidance
WORK BASED ASSESSMENTS
• Trainees are required to complete WBA's including CBD, Mini-CEX, DOPS and MSF. The exact number is dependent on stage of training (refer to ePortfolio for exact details). These should be completed throughout the post and not in the last few weeks. (Please lease with consultants directly to book these).
• Trainees should complete a multi-source feedback using their college-recommended process even if one has been completed within the previous academic year.
FEEDBACK AND THE JUNIOR DOCTOR’S FORUM
• Feedback on your management of individual patients is an important part of training and learning. It should be given in an appropriate environment by the appropriate person, and not cause embarrassment.
• Important issues may sometimes be best dealt with by involving the College Tutor, as well as the patient's Consultant, thereby ensuring that all is done in an educational way. This should occur within 10-14 days after any incidents.
• If you feel that at any time feedback has been inappropriate, report this immediately to either your Education/Clinical supervisor or the Paediatric College Tutor.
• There is also opportunity to give feedback to the College Tutor at the bi-monthly Junior Doctors Forums (See Educational Timetable for dates).
• If you do not feel comfortable giving feedback in a public arena, then it is also possible to provide feedback either to your Educational/Clinical Supervisor or the College Tutor.
TEACHING AND EDUCATIONAL OPPORTUNITIES
• The department offers a wide range of educational opportunities. It is the trainee's responsibility to attend and contribute to these activities
• A record of attendance at meetings is kept and discussed if required in appraisals. Failing to attend educational sessions may prevent trainees being signed off for their post
• Each month a Teaching Programme (date, time, venue, topic) will be emailed to all Paediatric and Neonatal clinicians, who must check to see if they are expected to be present at a meeting. If it is inconvenient, let the Paediatric Tutor know immediately
• These are usually hybrid meetings, but with no expectation to join if on an off day
X-RAY MEETING
• 2nd Monday pm and 4th Friday lunch
List of x-rays for discussion to be sent to Dr Amarnath by Friday (week 1) or Monday (Late additions possible up until Wednesday 2pm)
• X-rays for discussion need to be highlighted at each post-ward round handover and added to the Radiology Template document that day (saved in the Paediatric Y: Drive). If possible please update template with outcomes for those discussed at the last meeting e.g. findings of further investigations at BCH or Alder Hey
• The Ward-Based SpR is responsible for overseeing this process
• A brief, verbal (30 second) case summary of each X-ray is required CAKE & CAT
• Informal teaching covering a case seen on the ward that week
• Session takes place after morning ward round on Wednesdays and all doctors on shift are required to attend
• The COW brings the cake!
PROTECTED PAEDIATRICIAN TEACHING
• Now on Wednesday afternoons 2-3pm
• These sessions are bleep-free for all paediatric trainees and the majority of other trainees should attend
• Teaching will cover general & community paediatrics, and basic neonates.
• Neonatal teaching also on a Wednesday afternoon and all are welcome to attend.
CRITICALLY ILL & INJURED CHILD
• On 2nd Monday afternoon monthly
• Review of the SCRAP (Sick Child Retrieval Assessment Proforma) plus a case presentation by the lead clinician for each case retrieved by KIDS or challenging case.
JOURNAL CLUB
Usual Thursday lunch (see monthly programme)
SpRs and Associate Specialists are expected to contribute. Time allotted is 60 minutes.
• Before the meeting:
• Choose a publication of importance and interest.
• Ideally analyse using the appropriate CASP tool https://casp-uk.net/casp-toolschecklists/
• Avoid publications from the "Archives of Disease in Childhood".
• Do not choose review articles.
• Ask Kim Bates (kim.bates4@nhs.net) to circulate the article to all clinicians at least 3 working days prior to the presentation.
At the meeting:
• Present why the article was chosen - relate to a recent patient(s) problem ideally.
• Present the article, and focus on key areas, including bias and statistics.
• Present other relevant evidence as appropriate.
• Take questions.
• Summarise with key learning points.
• Suggest changes in practice.
After the meeting:
• Write reflective notes in portfolio.
• Liaise with education supervisor/consultants for feedback.
• Take forward suggested changes in practice.
GRAND ROUNDS
• Monthly – timetabled on the Educational Programme.
• An opportunity for trainees to develop presentation as well as critical thinking skills.
SHROPSHIRE MONTHLY CPD MEETINGS
• Held on first Monday of each calendar month.
• Clinical and audit topics, frequently with outside speakers.
• Focussed on Consultant and Associate Specialist/Speciality doctors, but Junior tier and SpR attendance expected depending upon ward workload.
SAFEGUARDING MEETINGS
• On 4th Monday afternoon monthly.
• Case presentation by examining clinician of all cases seen in the preceding month, followed by Team review discussion.
PROTECTED TEACHING
The many academic activities that take place cannot be protected for all clinicians. But it is important to organise routine work and cover, and so to maximise attendance. This should be possible with understanding and co-operation.
JUNIOR TIER
• Nationwide training for FY1+2, GPVTS & Paediatric ST1-3 is all protected, and the wards will be covered by Middle Tier Doctors and ACPs.
• Departmental ST training on Tuesday &, and regional teaching on Wednesdays is protected for Paediatric and Neonatal junior tier.
• All other teaching sessions are not strictly protected, with 1 doctor staying on the ward to deal with emergencies (Long Day Middle Tier)
MIDDLE TIER
• Regional SpR study days () are protected for core ST4+.
• Attendance is expected unless on annual, study or sick leave or night shifts.
• If ST4+needs to stay back for patient care, then the decision needs to be made by the COW to facilitate teaching attendance. Emergencies during this period, are managed initially by SAS , ACP’s or consultants.
• The Lunch-time meeting is also local protected teaching.
ASSOCIATE SPECIALIST
• Associate Specialists are expected to attend the Monthly CPD and Audit meetings, hence the bleep should be answered by the SPR.
• Workload should be organised to facilitate attendance at several other academic activities: Perinatal Mortality/Morbidity; Feto-maternal meetings; Special Study Days.
OUTPATIENT CLINICS
• General Paediatric Out-Patient Clinics are held by the Consultants almost every morning unless cancelled because of leave. Speciality clinics are also held, mainly in the afternoons.
• There is an opportunity for most to attend clinics, and observe, clerk and present as appropriate. If there is no clinic the rostered doctor is expected to attend ward work. Clinics usually start at 09:00am and 13:30pm
• Please be punctual
MIDDLE TIER & OUT-PATIENT CLINICS
• Middle-grade attendance at general paediatrics out-patients is agreed at the start of their attachment. The rota manager will roster people to specific clinics each month. There is also a monthly SPR review clinic that runs alongside Rapid Access Clinic.
JUNIOR TIER & OUTPATIENT CLINICS
• Paediatric trainee junior tier doctors are expected to attend a minimum of 10 outpatient clinics in 6-months (RCPCH recommendation)
NIPE* EXPERIENCE
(*Newborn and Infant Perinatal Examination)
• Junior tier trainees are expected to be trained in new-born baby examination; this is currently available on site in the Postnatal ward.
• This should be allocated by the Rota Manager
• You are expected to attend the Postnatal ward to gain experience in NIPE under the supervision of the Neonatal SpR/Appropriately Qualified Midwife.
SICK, ANNUAL AND STUDY LEAVE & THE ROTA
SICK LEAVE AT START OF SICK LEAVE
• The doctor must inform Medical Staffing:
o Mon-Fri 0900-1700: 01952 641222 ext. 4410
o All other times: 01952 641222 and request the on-call Medical Staffing, or direct on 07807 720055/Agile.
• The doctor should provide:
o Site worked on
o Grade, Team and Rota commitments
o Likely number of days off work
• The doctor must also inform the COW on bleep 244 or 239 via switchboard AFTER 0930 hours.
• Do not use WhatsApp to inform the CoW. But it is helpful to let the team know on departmental WhatsApp group prior to discussing with COW.
Medical Staffing will
• Email the doctor the required "Return to Work" paperwork to be completed when sickness period ends.
• Speak to (not email) the COW (bleep 244) to discuss locum requirements.
The Consultant Paediatrician will:
• Inform the relevant rota manager, and
• Contact the Paediatric Business Team to request help with locums if required DURING SICK LEAVE
The doctor must:
• Keep medical staffing informed of progress or change of return date.
• Provide a doctor’s note (aka a "Fit Note") for sick leave beyond 7 days.
ON RETURNING TO WORK
The doctor must:
• Inform medical staffing
• Complete the "Return-to-Work" paperwork (see below)
• Arrange a "Return to Work" interview with the COW.
RETURN-TO-WORK INTERVIEW
• It is your responsibility to arrange a Return-to-Work Interview (RTW). This should be arranged with the COW or the Paediatric Tutor if the COW is unavailable.
• RTW forms are available on the intranet for your completion.
• Refer to the Trust's sickness policy, available on the Intranet for more detail.
• Failure to do the above will mean that you will continue to show as being off work and your pay may be affected.
THE ROTA CO-PRDINATORS
• The rota will cover daytime duties as well as on-call commitments.
• A designated junior & middle tier trainee will support the Consultant Paediatrician managing the paediatric rota, with and ACP (Neonates) supporting the neonatal rota.
o PAEDIATRICS
▪ Junior Tier: Dr Santwana Dwivedi/Shanice
▪ Middle Tier: Dr Manish Gupta
o NEONATES
▪ Junior Tier: Jenny Lamb, ACPN
▪ Middle Tier: Dr Manish Gupta
ANNUAL & STUDY LEAVE
ANNUAL LEAVE
• All A/L dates must be agreed upon and booked within the first 2 weeks of the post to ensure that disappointment does not occur
• Failure to book A/L at the start may result in subsequent leave requests being refused if cover of the ward is compromised.
• The Trust will not pay for unused annual leave.
• The doctor organising the rota is responsible for ensuring that leave does not compromise service delivery.
o One full week is taken this = 5 days A/L.
o Two full weeks taken = 11 days A/L (middle Saturday is counted)
• Leave forms are available in the "Paediatric Rota" folder in the "Paediatric Y:Drive". The form MUST be signed by the junior doctor organising the rota and the Consultant rota supervisor.
STUDY LEAVE
• Educational opportunities are encouraged within the department.
• Study Leave must be booked early to avoid disappointment.
• Study leave forms and up to date advice on applying and claiming expenses is available on the SaTH Intranet navigated as: Intranet > Post-graduate medical education > Study leave
• Annual leave rules above are applicable to study leave
GOVERNANCE
GOVERNANCE FEEDBACK
• Monthly Clinical Governance Feedback meetings are held every 3rd Monday afternoon –see Educational Programme.
• Serious incidents, High-risk Case reviews, Datix reports, Audit, Guidelines,
• Complaints and other issues are summarised & are essential learning for all
• Individual clinicians should also request feedback on any Datix that they submit and discuss outcomes with their Supervisor.
AUDIT
• Involvement in audit is a requirement of continuing professional development. Discuss projects and involvement with your Educational Supervisor at start of post.
• Audit support can be provided by the SATH Clinical Audit Department.
• Dr Kumar Sethuraman, Consultant Paediatrician & Audit Lead, can suggest topics and give advice.
HOW TO REGISTER AN AUDIT
• Download an Audit Proposal & Summary form from the Intranet Paediatric Section (under Clinical Services)
• Complete the proposal section of the form with your ES (or other agreed Consultant)
• Submit the proposal to Dr Sethuraman (s.sethuraman@nhs.net) plus any data collection form being used in the audit & send copies to your ES. You will be notified of approval of the need for changes by Audit Steering Group
AUDIT PRESENTATION & ACTION PLANNING
• Present your findings to your ES
• Agree a proposed Action Plan
• Arrange via Dr McCrea for a date for presentation of your audit
• After presentation complete the Summary section of the Audit Form with your Audit Supervisor, agree an Action Plan and email to Dr Sethuraman
• For certain projects (large scale or high profile) an audit report may be required in an addition to the audit summary GUIDELINES & PROTOCOLS
• Clinical guidelines, Standard Operating Policies and Pathways of Care are accessed from any networked PC in the hospital via the Intranet:
→ Homepage → Clinical Services & Departments →Paediatrics
• In addition, West Mids Partners in Paediatrics clinical guidelines are accessible via
• There are monthly guidelines meetings. You may be required to contribute to these meetings and to the development and review of guidelines within the department.
CLINICAL INDICENTS (DATIX REPORTING)
• Near misses, not just actual errors, should be reported. This way we may prevent accidents from occurring.
• The department is committed to a concept of a "no blame" culture and encourages the completion of clinical incident forms by all members of staff.
• Incidents are reported using the Datix system, via the Intranet homepage app section.
• Junior doctors seldom report clinical incidents but are more likely to have witnessed one than other doctors.
PRESCRIBING
Prescribing error is the commonest reason for error/Datix completion. Clinicians must:
• Take time to prescribe, and in an appropriate environment - away from the ward-round or the busy acute environment.
• Record calculations in the notes where appropriate - IV fluid calculations and complex calculations in particular
• Be trained and remain up to date with reference to the BNF for Children and the Neonatal Formulary.
Read & follow the "Prescribing in Paediatrics” guideline on the Intranet. OUT OF HOURS PRESCRIBING
• A stock of medications for dispensing OOHs is available on Ward 19, the CAU and the EDs
• If a required medication is not available from ward stock OOHs Doctors may prescribe on an FP10, kept securely in locked cabinets.
• Ask a member of the Nursing Team, and sign out an FP10 recording your name, patient's name, the FP10 unique number and date.
• Prescribing for staff, friends and family is prohibited and against GMC regulations
• Please ensure during daylight hours (9-5) TTO’s are highlighted to pharmacy in a timely fashion. IF needed white Prescriptions can be used instead of FP10’s.
HEATH & PREVENTION OF STRESS
Working with sick children and their families can be stressful, so if you are struggling consider the following:
• Discuss problems with your Educational Supervisor, or any of the Consultant Team
• Look at the Intranet homepage, and in the “Our Worklife” section click on “Mental Wellbeing” to access many really helpful support organisations or eEmail: sath.ahealthieryou@nhs.net
• TRiM, a trauma focused peer support system designed to help people who have experienced a
• traumatic, or potentially traumatic, event is available at SaTH To contact a TRiM Practitioner
• Contact the W Mids Deanery Professional Support Unit via: https://www.westmidlandsdeanery.nhs.uk/Support/Professional-Support/AdditionalResources.
• The Academy of Medical Royal Colleges offers a range of support including DocHealth and the Doctors Support Network, accessible online by Academy of Medical Royal Colleges Support for Doctors (https://www.aomrc.org.uk/supportfordoctors/#1465858914205-3cac3324-6baf)
• Contact the Occupational Health Department. This service can provide counselling sessions.
• Ring "CONTACT" on 0121 5580278, a confidential, free, and independent counselling service especially for doctors.
• Speak to your GP
• Ring the Samaritans on 116 123
Please take early action so that staff can support you through any difficult time.
WARD SECURITY
• There have been instances Nationally of illegal/false entry to a Children's ward of NNU.
• When exiting NNU or wards ensure that visitors are only admitted if the ward clerk, nurses or you can ensure they have a valid reason for admission.
• A polite request for the visitor’s relationship to the patient, and the patient's name is always appropriate.
DICTATING LETTERS
• Parents and carers have a right to see all letters that are sent to healthcare professionals.
• Secretaries routinely copy all clinic letters unless parents have chosen not to receive them.
• Letters should be succinct and easy to read, avoiding unnecessary medical jargon
• Where possible, letters should have the following headings:
o Problem/diagnoses list
o Current medication list
o Management
o History
o Examination findings
o Conclusions & Management Plan
o Information given to parents
o Follow-Up arrangements
• The named consultant will check all clinic letters before they are sent out.
• For Child Protection Medical’s the dictaphone is kept in the drugs room in COPD, with the required paperwork. Please leave in here and email carol.binsley@nhs.net to ensure dictations are typed in a timely manner.
MAJOR INCIDENTS
• The hospital has a Major Incident Plan, a copy of which is available in the Children's Ward Manager's Office. A copy is on the intranet. It details the responsibilities of all specialities & grades of doctor. You are advised to read this.
• Not all major incidents involve paediatric casualties, but the scale of the incident may mean the paediatric senior or junior staffs are required to assist with the injured.
• A "flash card" for the SHO and the middle-grade on-call is held in the ward. This details an individual's exact role in a major incident, and staff must read this at the first warning of a major incident and follow its instructions.
• The consultant on-call will contact doctors as and when they are required
AMBULANCE TRANSFER INSURANCE
• The Trust has arrangements with its Insurance Brokers to cover doctors during Ambulance transfers, known as Corporate Indemnity.
• This does not however replace the individual liability cover provided by the Medical Defence Union or Medical Protection Society which the Department strongly advise you obtain. Subscription is also tax-allowable.
GENERAL PAEDIATRICS
WARD 19 KEY ROLES, THE WARD ROUND & HANDOVER
The Shift Patterns
0900 - 1700 Shift
• Attends handover at 0900 in Staff Room.
• Any imaging needed (USS/Xray/CT) outlined in handover with request cards handed in as early as possible. Night team to have request cards completed ready for handover.(May be in the pink folder in the Dr’s office).
• CAMHS referrals are completed straight after handover if not done by the night team via online form and emailed.
• One person is allocated to sort out the TCI's (e.g. MRI under sedation, IV infusions). Once these jobs are completed then that doctor is to join the ward round. (This Tier one usually starts at 8am and finishes at 4pm).
• Attends Ward Rounds, the post ward-round handover, and actively engages with the ward work for the day - see below.
• The CAU team must inform the ward team of all admissions – use the SBAR stickers (see Paediatric Handover of Care SOP on this transfer process from CAU to the ward) and the handover sheet is updated accordingly with any outstanding actions
• Assist CAU team as required.
0900 - 2130 "Long Day" Shift
• 0900-1700 - as for 0900-1700 shift
• Part of Resus team responding to 2222 calls
• Maintain and distribute the Handover sheet
o During the post-ward round handover
o Prior to the 1630pm and 2100pm Handovers.
o Perform a walk around the ward prior to the Handovers to clarify all jobs completed and current clinical status of the patients/bed availability
• Everyone needs to take responsibility for updating the handover list, but ultimate responsibility is the Long Day Doctor.
• Informs the CoW when resident of any admission to the ward from CAU or the ED 2100 - 0930 "Night" Shift
• Attend Handover in Staff Room at 2100
• Complete any outstanding reviews and jobs with the Registrar.
• Update the Handover sheet throughout the night.
• Print the Handover List ready for 0900 Handover.
• Start prepping discharge letters.
• Complete any CAMHS referrals for overnight admission.
• Sign off paper results and action them appropriately - bring to Handover as required for COW/COD/Middle-tier to assist.
• Calculate accurate input-output fluid balance charts for those children on IV infusion or have input/output concerns.
• Walk-round to review all patients at 0630am prior to nurse change over to get an update of events overnight.
• Morning bloods to be taken prior to handover to assist with ward round.
• Deliver the handover - focussed SBAR approach recommended.
HANDOVER
• Seriously unwell or unstable patients need to be discussed first.
• CAU patients handed over next, CAU staff then go straight to CAU to start reviewing patients, review the results book and other administrative duties (see CAU Working Guide)
• Planned admissions for the day are outlined at handover with a person designated to managing these patients and then joining the ward round after if time allows
• Remaining patients handed over in an SBAR manner, outlining new problems overnight, providing important information including:
o If on IV fluids: fluid balance and urine output in mls/kg.hr
o If on oxygen: delivery method, rate/concentration, and oxygen saturations
o Important outstanding investigation results
• Potential discharges outlined.
• Any imaging needed (USS/CT/Xray) outlined in handover with request cards handed in as early as possible. Night team to have request cards completed ready for handover.
WARD ROUND
• Seriously ill or unstable patients are seen first.
• Split into 2 teams: One consultant starts on Oncology and the other at the “Horseshoe” .
• At times of bed shortage, potential discharges are seen after ill or unstable patients, and junior tiers leave the ward round to complete the discharge summary
• If Middle-tier paediatrician is available, then they may also see patients independently, but new admissions should be seen by a consultant also
• Junior staff to split equally and assist with preparing the notes.
• All new admissions must be seen by a consultant on the morning ward round.
WARD ROUND DOCUMENTATION
As a rule, every morning ward round each patient will require the following information written in the notes:
• Date + Time and which parent or carer is with the child
• Name of Consultant/middle-tier seeing the child
• Working Diagnoses
• Most recent observations and PEWS score
• Medications and oxygen delivery (mode and concentration)
• Input/output - UO in ml/kg/h
• Brief history
• Examination (& weight, height + BMI & centiles if not already calculated on admission)
• Clinical impression
• Plans
• Info given to parent/carer
• Your name, GMC and signature.
POST WARD ROUND HANDOVER
• Long Day Shift doctor updates the Y-drive Handover List, another updates office whiteboard with Discharges (definite and likely), jobs, reviews & patients to be discussed in X-ray meeting.
• Updates on patients' clinical status and outline management plan/jobs for completion.
• Jobs, discharge letters and patient reviews are shared equally between the staff for completion during the afternoon with the team member's name responsible being written next to the allocated job.
• Once jobs are completed, they are crossed off on the board, the Long Day doctor informed of their completion/outcome & the Handover List updated
• Discharges for the day outlined to the Nurse-in-Charge to help plan beds.
• Blood tests require the following people to be informed: parent/carer, patients named nurse and play specialist. This facilitates application of Ametop if required.
• Ensure discharge letters for TCI's have been completed.
• Received a handover from CAU staff for any patients requiring admission, signing the Handover sticker (see Paediatric Handover of Care SOP)
THE HANDOVER LIST
• Maintained by the Long-Day/Ward Night shift doctor.
• Printed and distributed in readiness for the 0900, 1630 and 2130 handovers.
• Outline un-well patients and important jobs for completion in bold.
• Record patients names and problems on CAU section, along with any new patients expected
• All new patients to be entered in bold if needed to be seen by a consultant.
• Highlight patients in light grey text if to be discharged that day but not yet left the building.
• Any outstanding jobs after a patient has been discharged need to be added to the "Jobs List" at the bottom of the handover list.
• Please keep brief to ensure confidentiality and succinct handovers.
• For access to the Y Drive please scan QR Code in Drs office. Dr Brough co-ordinates this.
HANDOVER ATTENDEES
TITLE & TIME
Morning Handover 0900
Post Ward Round 1130 approx
Afternoon Handover
ATTENDEES LOCATION
COW & COD; Ward 19 Middle Tier, CAU and Ward 19 Junior Tier, Nurse-in-Charge.
COW & COD; Ward 19 Middle Tier, Ward 19 Junior Tier, Nurse-in-Charge.
COW & incoming On-Call consultant; Ward 19 Middle Tier, Incoming Long-day Middle Tier, Long Day Junior Tier, All other Ward 19 Junior Tier, Nurse-in-Charge.
Evening Handover On-call consultant; Long Day Middle Tier, Night Middle Tier, Long Day Junior, Night Junior, CAU Junior or Middle Tier, Nurse-in-Charge
CAU ROLES & DAILY STRUCTURE
Staff Room
Doctors Office
Staff Room
Staff Room
For more detail refer to the separate document “CAU Working Guide”
SHIFT PATTERNS & KEY ROLES
0900 - 1700 SHIFT
• Attend Handover at 0900.
• After CAU patients are handed over go straight to CAU to start reviewing patients and the Results book. (Black folder and the results list at the bottom of the handover list). A short day person should be allocated to do the results book and Paeds emails. This should be rotated around.
• Manage referrals: clerking, investigation, management, admission and discharge.
• Discuss all clerking's with a Middle-Tier or above. 1300-2200/2300 “Twilight” SHIFT
• Key roles as for 0900-1700 CAU shift.
• Attendance at 1630 or 2100 Handovers are not required.
ADMISSIONS & DISCHARGES
• Referrals can only be accepted by a Middle-Tier or Consultant Paediatrician.
• Admissions come from 6 main sources:
o ED
o Primary Care (General Practitioner or Advanced Clinical Practitioner)
o Open Access
o Community Midwife
o Ambulance Crew for infants <6 months
o Social Services
o Consultant Paediatrician
o Elective admissions
ED FAST-TRACK ADMISSION DIRECT TO CAU
Children aged <6 months presenting to the PRH A&E with medical problems can be transferred direct to CAU after ED nurse triage & PEWS scoring, if not requiring resuscitation/immediate care (see guidelines)
ADMISSION TO ED RESUSCITATION ROOM
The following groups should be admitted via the ED Resuscitation Room:
• Trauma, particularly neuro-trauma
• "Blue Light" emergency admissions that have not been assessed by a Primary Care Doctor
• "Blue Light" emergency admissions with stridor, or presumed severe/life-threatening upper airway obstruction
• Children for whom intubation is thought likely
• Children for whom immediate access to Radiology is deemed likely.
ON ADMISSION TO CAU
• Nurses will triage within 15 minutes and categorise patients as green, yellow, orange, or red depending on the urgency of the assessment they require.
• SHO/ACPP's complete the initial clerking using a standardised clerking proforma and formulate an initial differential diagnosis and plan.
• For concerns about an acutely unwell child escalate as soon as possible.
• All patients must be reviewed by either the CAU registrar or COW/COD, with a decision to either discharge or admit.
• Patients admitted directly to the ward either from clinic/A&E need a paediatric clerking and clarification of the plan from the responsible consultant/clinician.
• TCI patients can come in for MRI, DMSA and infusions. They require clerking and IV access if necessary. Typically, these are day cases and so require a discharge letter.
• If the patient is admitted, it is the responsibility of the clerking doctor to inform the Ward Long Day doctor and provide a handover of working diagnosis and outstanding jobs.
• If the patient is acutely/critically unwell then inform the Ward Registrar to facilitate early review post transfer to the ward.
POST ADMISSION TO CAU
• Any patient discharged with outstanding results (bloods, swabs, urine microbiology etc.) need to be entered into the results book for checking on subsequent days.
• It is the responsibility of the clinical staff on CAU to check the results book daily and inform the patient/GP of any significant results.
• If the patient is admitted it is the responsibility of the clerking doctor to inform the Ward Long Day doctor and provide a handover, providing name, DOB, hospital number, diagnosis, clinical details and outstanding jobs.
CAU FOLLOW-UP
• Decision to discharge may only be taken by middle or senior-tier clinicians.
• Follow-up slots are finite & must be booked through the nurse in charge of CAU.
• Follow-up options are:
o Early follow-up post-discharge, as a one-off, can be requested in the RSH PMDU Clinic, or if no capacity can be via CAU, again as a one-off only.
o Routine General Paediatric Consultant follow-up: under the admitting consultant, arranged by Ward Clerk.
o Speciality Paediatric Follow-up: requires a typed referral letter to the consultant and must not be booked by the Ward Clerk.
o A child should not be brought back to CAU for a second CAU review by a MiddleTier doctor unless the child's consultant is involved in this decision process and plans made for subsequent follow-up in a consultant outpatient clinic.
Tertiary referrals.
• Cardiology referrals (BCH) – Please email pro for a from Paeds email to cardiology team and follow up with a phone call to ensure safe recipient. Please note cardiology SPR’s at Birmingham Children’s are on call from home overnight.
• Neurology – BCH-tr.neurologyoncall@nhs.net. With a clear history and any outstanding investigations.
Both of the above must be uploaded onto Clinical Portal.
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PAEDIATRIC MEDICAL DAY UNIT AT RSH
The RSH CAU does not accept acute referrals. Its functions include:
• Phlebotomy for children with difficult access
• or age <12 months who cannot attend the RSH or PRH phlebotomy facilities.
• Programmed investigations
• BCG clinic
• Prolonged jaundice service (SATH.PJS@nhs.net).
• Follow-up for a one-off specific reason – Consultant decision only
To refer a patient for phlebotomy just email on cau.rsh@nhs.net. Or discuss with COPD nursing team for phlebotomy appointments.
All other referrals require completion of a CAU follow-up proforma
SPECIALTY PATIENTS
SURGICAL
• Clerking undertaken in CAU by paediatric junior tier. If felt to be surgical cause discuss the patient with the Surgical Registrar (Bleep 208).
• There are no surgical registrars present in the hospital overnight. If critically unwell then discuss with the paediatric registrar overnight, otherwise the patient can be admitted to the ward to await surgical review in the morning.
• Please ring the on-call surgical registrar at 0700h if a surgical patient requires a review on the morning surgical ward round.
• To facilitate their assessment, ensure relevant bloods/urine dip have been completed ready and documented clearly in the notes.
• The surgeons will attend the ward between 0800-0900 and will normally inform the paediatric team of key issues
• Assist the surgeons in the prescription of IV fluids, analgesia etc.
• Please clarify NBM status and planned surgical time.
• You are required to complete the discharge letters for all surgical patients EXCEPT orthopaedic cases.
ENT
• Majority of simple ENT problems can be managed by the paediatric team
• Any conditions where it is felt a surgical opinion is required (e.g. pre-septal cellulitis, quinsy, foreign body), the ENT SHO/Reg needs to be bleeped (ENT SHO 891).
• ENT ward rounds will review the patients between the hours of 0800-0900.
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CAMHS
• Clerk the patient and assess both their medical and psychiatric history.Please complete a HEADDSS assessment also.
• Any indication of overdose refer to ToxBase (Intranet Paediatric Guidelines) to ensure adequate management is implemented.
• Please consider early discussion with Kerry (Youth Worker), Julie (TMBSS Teacher) or Sarah (RMHN) and the play therapy team to ensure risk assessment completed.
• Once the patient is medically fit complete the CAMHS referral form as early as possible to facilitate a prompt CAMHS assessment.
• Advice and support are available from the CAMHS crisis team 7 days a week – please refer to the CAMHS pathway documents on the Intranet
• Not all CAMHS patients require admission but all should be referred for an urgent CAMHS assessment. Only CAMHS patients with a medical need may be admitted to the paediatric ward (requires consultant discussions).
• Referral forms are saved in the Paediatric Y: Drive. A copy needs emailing to CAMHS and a cop printing and filed in the Pink folder present on the wall in the Doctor’s office.
• Emails must be sent from the paediatric ward email (not your own personal email): prh.paeds@nhs.net (password is available on the ward)
TRAUMA & ORTHOPAEDICS
• Many T&O admissions will be seen in either A&E or Fracture Clinic and admitted to the ward for surgical correction of their fracture.
• Some patients may go straight to theatre and return to the ward for post-op recovery. These patients still require a paediatric clerking to ensure that any other medical conditions are managed appropriately.
• Any patient referred to CAU with a swollen joint or inability to weight bear need to be referred to Orthopaedics for assessment.
• All patients need to have a VTE assessment completed.
• Clarify with the surgeons whether tinzaparin is required.
• Any paediatric trauma must be managed as per the PRH Trauma Guidance and low threshold for discussion with TTL at Birmingham Children’s Hospital.
ONCOLOGY
• All known oncology patients have open access to the oncology unit and will come to the ward directly when they are unwell.
• The Oncology On-call Consultant Paediatrician (see RotaWatch) must be informed of all admissions within 24 hours including at the weekend.
• Any patient who is unstable must be escalated to the on-call Consultant Paediatrician.
• Out of hours the On-call Consultant will liaise with local oncology Consultant team. If they are not available, the patient should be discussed with the BCH oncology team. This may be done via a KIDS conference call if the child’s condition is sufficiently concerning.
• There are detailed guidelines for the management of oncology patients available on the intranet.
• You will NOT be asked to prescribe chemotherapy.
• Please ensure you have completed the blood transfusion e-learning package as you will be required to prescribe blood products (you will be trained and supported to do this)
CYSTIC FIBROSIS
• All CF patients attending the CAU or admitted to the ward must be discussed according to the Intranet guideline “Cystic Fibrosis – Assessment and Admission”.
• Attending patients must not be discharged without consultation as specified in the guideline.
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DIABETES
• The Diabetes on-call Paediatrician (see RotaWatch) should be informed of all patients admitted, on the day of admission including weekends particularly for newly diagnosed patients
• Ward nurses should also let the Diabetes Nurse Specialist know of the admission.
• Ketoacidosis is an emergency, and should be prioritised as such, with middle grade involvement as soon as possible in all cases.
• Diabetic patients are told in an emergency to access advice regarding blood sugars, particularly after hours, by contacting the paediatric middle-tier via switchboard. The middletier clinician should use the specific proforma (“Telephone Advice to Diabetic Patients” form on the Intranet guidelines.) to record the conversation and advice given (kept in a folder at the ward desk). If a patient contacts the Ward or CAU they should be advised to contact the middle-tier via switchboard unless available on the ward.
READMITTING BABIES TO THE NEONATAL SERVICE
• Due to potential infection risk and staff training, the re-admission of a baby to the Neonatal Unit is avoided. There are though exceptional circumstances when this may occur, such to provide Intensive Care support that is not possible on the Children’s Ward and when retrieval by the KIDS Team is not possible. Such events are rare, and can only take place by agreement with the on-call Paediatrician, Neonatologist, Neonatal Unit Manager and the KIDS Team
• Re-admission to the Post-Natal Ward/Midwife-Led Unit is appropriate in certain situations i.e. weight-loss or jaundice (see Guideline “Readmission of Babies from Home, less than 10 days Old):
o Babies should first be clinically assessed on the CAU
o If there is evidence of infection or problems other than jaundice or weight loss the baby should be admitted to Children’s Ward after discussion with the consultant paediatrician on-call.
o Any readmission to the Neonatal Service should be agreed with the consultant neonatologist on-call.
BLEEPING A PAEDIATRICIAN
• For paediatric emergencies:
o Dial 2222 and instruct Switchboard "Paediatric emergency at ... (Location)"
o Say this twice
• For any bleep number in this Trust dial "77", wait for the voice prompt and then key in the bleep number followed by an extension number.
• For details on specific bleep numbers see:
o Intranet Guidelines “Bleeping a Paediatrician”, “PRH Bleeps” and “RSH Bleeps”
o Inside cover of the Paediatric Referral Proforma
o Search on Phonebook app on Intranet Home- page
TELEPHONE ADVICE
• Parents and carers may telephone the ward for advice, especially when they have been given Open Access
• It is essential that a permanent record is made of this advice given by any member of staff, and a consultant reviews that advice.
• When giving telephone advice:
o Please document a clinical note on clinical portal.
o Children under the care of a consultant or on open access: follow the Open Access Standard Operating Policy.
o When giving advice; always consider first whether a more senior doctor should be consulted.
CONTACTING CONSULTANTS OUT OF HOURS
• When a non-resident consultant is required URGENTLY out-of-hours or on weekends the following actions are expected:
o Request switchboard to contact the on-call Consultant via their mobile/landline stating that this is an emergency with the consultant required potentially to return to hospital immediately.
o Stay on the line whilst Switchboard makes the connection.
• We encourage the nurses/Nurse-In-Charge to contact the consultant out-of-hours if they have any concerns regarding a specific patient’s management or the capacity issues. They are independent practitioners and have a duty of care to our patients/overall service to ensure safe and high-quality care.
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CLINICAL GUIDELINES & SOPs
• There are comprehensive clinical guidelines for Paediatrics, and Standard Operating Policies (SOPs), all accessed via Intranet > Clinical Services & Departments > Paediatrics
• The Intranet holds the most up to date versions. Paper copies should not be printed out/relied upon
• SaTH Paediatrics is also a member of the Partners in Paediatrics (PiP) Consortium, with access to the PiP Paediatric Guidelines: www.ebcgp.co.uk Username paeds1 Password PiP-2@-2@ PRIORITY GUIDELINES TO BE READ AT VERY START OF POST
• It is not expected, nor possible, to have read all guidelines and SOPs by the start of your post
• However, within the first week of start of post it is expected that clinicians will have read the following important guidelines:
o Asthma
o Anaphylaxis
o Analgesia
o Bronchiolitis
o Croup
o Diabetes Ketoacidosis
o Gastroenteritis
o Meningitis
o Meningococcaemia
o Oncology & Febrile Neutropaenia
o Pneumonia
o Poisoning/Use of ToxBase
o Prescribing medicines
o Sepsis
o Status epilepticus
o Transfer of Children, and Time-Critical Transfer to a PICU
o When to contact the Consultant On-Call
Also to be aware of the SCRAP forms and the yellow deteriorating patient forms to be used when escalating concerns. Only a middle grade or above can sign off on the Sepsis 6 forms.
BLOOD & MICROBIOLOGY SAMPLES
• POD system available behind nursing station by C-bay - instructions for use on the machine.
• Deposit box for samples to be collected by porters is located on the ward clerks' desk in the entrance between CAU/Ward 19.
o Code for Deposit Box - 0099
o If Deposit Box used overnight/for urgent sample at any time, then needs to be TeleTracked for a porter to come and collect
• Always phone the lab when sending a CSF sample to microbiology, as they do not have a 24/7 presence and may need to return to the hospital
o The biochemist will not do this for you and so analysis may be delayed or even become unsuitable for analysis.
o Taxi transport to RSH site is required for OOH samples – PRH Lab staff will organise the transport of samples from PRH to RSH as required
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RADIOLOGY REQUESTS SaTH
REQUESTS
MODALITY GUIDANCE
CXR
USS
CT
MRI
In-hours: Phone department to request (4210)
Out-of-hours: Bleep on-call Radiographer (4210)
Non-urgent: Send form in post to Radiology Office
Urgent: Discuss with Consultant Radiologist (ensure scanned onto CRIS first).
Consultant Paediatrician approval required
Non-urgent: Send form in post Radiology Office
Urgent: Discuss with Consultant Radiologist (Ensure form scanned onto CRIS first)
Consultant Paediatrician signature on Request Form required
Non-urgent: Send form in post to Radiology Office
Urgent: Discuss with Consultant Radiologist (Scan onto CRIS).
Play Therapist Support required for age 4-7yrs (2 slots/week)
Sedation required for age up to 4yrs
TERTIARY CENTRE RADIOLOGY
Centre MODALITY GUIDANCE
BCH
MRI & CT Requires completion and emailing of the form "BCH External Request Form" - scroll down to bottom of page
Alder Hey MRI & CT
and click on Useful Links & Documents, and down to “R” for Request/Referral Forms
Required written referral to "Consultant Radiologist" at the Alder Hey Hospital providing all relevant details and if there is the potential need for sedation or general anaesthesia. Email letters to ahc-tr.pacs@nhs.net
