Paediatric Assessment Unit Research Articles

Respiratory viral testing for young febrile infants presenting to emergency care: a planned secondary analysis of the Febrile Infants Diagnostic assessment and Outcome (FIDO) prospective observational cohort study

ObjectiveTo describe the association of respiratory viral test results and the risk of invasive bacterial infection (IBI) for febrile young infants presenting to emergency care.DesignA planned secondary analysis within the...

Telehealth in a paediatric developmental metropolitan assessment clinic: Perspectives and experiences of families and clinicians.

The application of telehealth in the paediatric setting is growing, and yet, limited research has focused on using telehealth in developmental diagnostic assessment and the consumers' perceptions of their telehealth experience. This study explored parents'/carers' and staff experiences of using telehealth as part of the developmental diagnostic assessment. Parents/carers who attended an assessment between June 2020 and July 2021 that incorporated a telehealth component within a hybrid service delivery model were invited to provide feedback about their experience of telehealth appointments at a multidisciplinary developmental assessment service. All parents were invited to complete an online survey, with a sample of families being offered a telephone interview. Staff members were invited to a focus group to explore their experiences of delivering services via telehealth. Data obtained were analysed descriptively and thematically using a mixed method of analysis. Codes were categorized, enabling facilitators and barriers to be explored. The use of telehealth in the diagnostic assessment of complex developmental disorders received high levels of acceptance from parents/carers and staff, despite having limitations such as technical issues, difficulties building rapport between families/clinicians and limited direct observations of the child. Telehealth services are perceived to reduce costs and increase flexibility, including increased ability to accommodate family needs. Results demonstrated that telehealth is a highly acceptable mode of service in a developmental assessment service. The current study informs the development of a hybrid service delivery model by enhancing facilitators and reducing barriers commonly reported by consumers and provides direction for future research. Parents or carers of children who attended a tertiary paediatric assessment unit for a diagnostic developmental assessment completed the online survey and were interviewed.

Improving paediatric flow in an UK Paediatric Assessment Unit

The 2010 Royal College of Paediatrics and Child Health (RCPCH) guidelines for acute paediatric services set standards for time to senior review for paediatric medical admissions in the UK as...

The association between opening a short stay paediatric assessment unit and trends in short stay hospital admissions

BackgroundMany inpatient facilities in Scotland have opened short stay paediatric assessment units (SSPAU) which are clinical areas separate from the usual inpatient ward area and these are where most short stay (also called zero day) admissions are accommodated. Here we describe the effect of opening short stay paediatric assessment units (SSPAU) on the proportion of zero day admissions relative to all emergency admissions.MethodsDetails of all emergency medical paediatric admissions to Scottish hospitals between 2000 and 2013 were obtained, including the number of zero day admissions per month and health board (i.e. geographic region). The month and year that an SSPAU opened in each health board was provided by local clinicians.ResultsSSPAUs opened in 7 health boards, between 2004 and 2012. Health boards with an SSPAU had a slower rise in zero day admissions compared to those without SSPAU (0.6% per month [95% CI 0.04, 0.09]. Across all 7 health boards, opening an SSPAU was associated with a 13% [95% CI 10, 15] increase in the proportion of zero day admissions. When considered individually, zero day admissions rose in four health boards after their SSPAU opened, were unchanged in one and fell in two health boards. Independent of SSPAUs opening, there was an increase in the proportion of all admissions which were zero day admissions (0.1% per month), and this accelerated after SSPAUs opened.ConclusionOpening an SSPAU has heterogeneous outcomes on the proportion of zero day admissions in different settings. Zero day admissions could be reduced in some health boards by understanding differences in clinical referral pathways between health boards with contrasting trends in zero day admissions after their SSPAU opens.

Reaching the summit of discharge summaries: a quality improvement project

BackgroundDischarge summaries need to be completed in a timely manner, to improve communication between primary and secondary care, and evidence suggests that delays in discharge summary completion can lead to...

Consultant-led triage of paediatric hospital referrals: a service evaluation

ObjectiveWe established a paediatric demand management (PDM) service in our paediatric department in 2017. The aim of this consultant-delivered service is to manage referrals more efficiently by providing active triage...

The impact of different methods of COVID-19 sample analysis upon patient stay duration between arrival at the emergency department and hospital admission

BACKGROUND: Sars-Cov2 is a respiratory disease causing virus that originated in Wuhan, China with the officials in the country first reporting it in December 2019. It results in the condition Covid-19, with the main symptoms associated with the virus being a high temperature, a continuous cough and a loss or change of taste and smell.AIMS AND OBJECTIVES: An assessment of service provision was conducted to see how the involvement of different analysers with its different systems, impacted upon the duration that patients spent on Paediatric Assessment Unit (PAU); an intermediary unit linking the Emergency Department to further hospital wards. The preferred screening for the virus by Public Health England (PHE) involves molecular diagnosis by real-time PCR. MATERIALS AND METHODS: Fifty samples were collected between March and July, and the patient duration spent on PAU was seen to decrease as the months progressed. To the best of our knowledge, this is a novel study which has not yet taken place before.RESULTS: As the months progressed, the average time patients spent on PAU from March to July was shown to have reduced.CONCLUSION: The decrease in duration mirrored the change in service provision; namely the implementation of a random-access analyser, allowing for enhanced patient movement within the hospital.

Development of a paediatric short-stay observation and assessment unit.

In recent years children's emergency admissions have risen by 18%. In 2011 a team at a city district general hospital in England recognised that children were being admitted to the general children's ward and often only staying for short periods of time. After a review of the service a plan was put forward for the development of a paediatric short-stay observation and assessment unit. The unit has led to a reduction in ward admissions and offered opportunities for children's nurses to extend their roles in assessment and treatment. This article explores the planning, delivery and audit of this unit and offers an exemplar for other trusts considering a similar change to service delivery.

Self-assessment

Sophie is a 36 hour old baby who presented to the Paediatric Assessment Unit yesterday with 9% weight loss and poor feeding. Antenatal scans suggested Sophie was small for gestational age but she weighed 3.6 kg at birth and is the largest baby when compared to mother's four previous children. Pregnancy was otherwise uneventful and mother did not receive a glucose tolerance test. She was born by normal vaginal delivery in hospital at full term and discharged home 6 hours later; her mother noted that she struggled to take the bottle for feeds prior to discharge home. There are no risk factors for sepsis. Family history is unremarkable apart from Type 1 Diabetes Mellitus in the father and several of his family members. On examination, Sophie has a soft fontanelle, normal cardiovascular, respiratory and abdominal examinations. Both femoral pulses are palpable. She is not dysmorphic. Blood gas is normal except the blood sugar, which is 2.0 mmol/litre. A feed is immediately given by nasogastric tube as Sophie will not take the bottle. The feed is an appropriate volume based on 90 ml/kg/day every 3 hours. A blood sugar is repeated 1 hour after this feed and is found to be 1.4.

Predictors of fever-related admissions to a paediatric assessment unit, ward and reattendances in a South London emergency department: the CABIN 2 study

ObjectiveTo explore the risk factors for ward and paediatric assessment unit (PAU) admissions from the emergency department (ED).DesignProspective observational study.Setting and patientsFebrile children attending a large tertiary care ED during...

MON-PP178: Estimation of Body Fat in Adults Using a Portable a-mode Ultrasound

Rationale: Several paediatric nutrition risk screening tools have been developed yet no-one has demonstrated reproducibility and reliability outside of research. We explored nutrition screening in children attending the paediatric assessment unit, compared with standard anthropometric measures. Methods: Prospective study, n = 300 [median 3.15 yrs; SD ±4.97 yrs; 44.6% (n = 134) female; 25.7% (n = 77) 2). In the over 5 year olds 5.8% were thin [BMI-for-age (BAZ) 2).

MON-PP177: Should Paediatric Nutritional Risk Screening be Used in an Acute Care Setting?

Rationale: Several paediatric nutrition risk screening tools have been developed yet no-one has demonstrated reproducibility and reliability outside of research. We explored nutrition screening in children attending the paediatric assessment unit, compared with standard anthropometric measures. Methods: Prospective study, n = 300 [median 3.15 yrs; SD ±4.97 yrs; 44.6% (n = 134) female; 25.7% (n = 77) 2). In the over 5 year olds 5.8% were thin [BMI-for-age (BAZ) 2).

G567(P) Improving efficiency and quality of care in the paediatric assessment unit: Abstract G567(P) Table 1

Context The Paediatric Assessment Unit (PAU) in our District General Hospital arose out of necessity and occupies a small space with limited privacy. Acute attendances continue to rise and demand for PAU increases. Problem Some children wait an unacceptable time for senior paediatric review and flow through the unit is poor. Longer stays (>4–6 h) are inappropriate. Consultant input is variable and junior rotas are understaffed. Parental questionnaires stated dissatisfaction with waiting times and facilities. Assessment of problem and analysis of its causes A working group (consultant and trainee Paediatricians, senior nurses) aimed to standardise and improve quality of care, specifically, improving waiting times and patient flow. To assess the scale of the problem we: Formally audited current practice against national standards from RCPCH’s Back to Facing the Future (2013). Held consultation sessions with multidisciplinary PAU team. An assessment proforma including timings, observations, history, examination and predicted outcome was designed to aid data collection. Areas identified for improvement included: Consultant cover at peak times Facilities and space Waiting times to see a decision maker Early discharge/admission planning Parental information Intervention Some improvements were more challenging to tackle than others. We are exploring relocation of PAU to a more fit for purpose area. Consultants are reviewing working patterns to provide cover during peak activity. In the meantime we carried out simpler interventions: Following feedback we developed the integrated assessment proforma improving assessment efficiency and focussing professionals towards planning for likely outcome. Prescription boxes and prompts will encourage early interventions (such as antipyretics, dioralyte). A junior doctor dedicated to PAU should meet nursing team at shift start ensuring names +/- photos are on the PAU board. A full time trust doctor employed for consistent middle grade PAU cover (although sometimes fills rota gaps). Consultants to attend PAU after morning ward rounds and evening handover to discuss +/- review patients. Expected waited times standardised o Seen by doctor within 1 h o Seen by senior within 4 h Patient/parent information leaflet distributed, outlining what to expect from a visit to PAU. Study design Not applicable Strategy for change We produced Standard Operating Procedures outlining the above expectations. This was presented and e-mailed to all staff. Three months were allowed for changes to be embedded before re-audit. Measurement of improvement The results of our original and re-audit are summarised in the following Table1: There was an 18% increase in patients seen within 1 h and a 14% increase in patients seen by a senior within 4 h, bringing us closer to national levels. Although consultant input doubled with our initial interventions, it is clear that planned review of consultant working patterns is necessary for us to achieve national standards. Effects of changes These improvements led to reduced waiting times and earlier decision making and discharge from PAU. There is a tangible sense of improved parental satisfaction, although this is to be formally assessed. Lessons learnt/Message for others To produce adequate, consistent improvement requires a longer process of workforce planning and service relocation/development. However, we have shown that significant improvements can be made by going ‘back to basics’. Formalising and communicating expected standards, more efficient paperwork and maximising medical staffing, has been the mainstay to achieving improvement within our service. It can be difficult to obtain agreement for service developments from all involved, but we found involving all parties early in the process was beneficial. Please declare any conflicts of interest below We have no conflicts of interest to declare.

G552(P) Chasing outstanding investigations for patients discharged from the paediatric unit: system change

<h3>Context</h3> This project was undertaken in the paediatric department of a district general hospital. We involved medical, nursing and administrative staff. <h3>Problem</h3> There were two previous systems for chasing outstanding results for discharged patients. Those for patients seen on the Paediatric Assessment Unit (PAU) were recorded at time of discharge in a folder. Those for discharged inpatients were added to the inpatient job list with allocation to a named individual. We found these systems resulted in investigations being seen much later than date available with the prospect of adverse impact on patient care. <h3>Assessment of problem and analysis of its causes</h3> Random selection and analysis of 50 entries from the old system showed that 31 (62%) of results had been chased/actioned. Only 9 (18%) had documentation indicating results had been seen/actioned within 24 h of availability. Multi-disciplinary team (MDT) discussion concluded that a major contributory factor was that investigations were being listed in the order of generation without consideration of the potential result availability date. Consequently, if a colleague chased results which were not available within their time (typically one week) on shift, these investigations would not be routinely chased resulting in potential for numerous delayed results. Our aim was to devise a single efficient system to address all of these problems. <h3>Intervention</h3> Following further MDT discussion a jobs book was designed. This comprised of a page-per-day diary. Any patients discharged from PAU with outstanding results were entered on the page of the anticipated result date. Those discharged from the inpatient ward with results expected beyond 48 h would also be entered into the diary. Each entry would include: patient and clinician details (including bleep number); job details; and outcome and documentation. The responsibility of looking at the results expected on each day was that of the team on PAU. If a result was not available when expected, then a note would be added to a revised future date to ensure follow-up. <h3>Study design</h3> Observational study to assess effect of intervention. <h3>Strategy for change</h3> The MDT was apprised through circulation of emails and presentation at grand-rounds of the proposed new system, rationale, aims and rules of use. Feedback was sought via email and verbally. Proposed changes were agreed with key stakeholders and colleagues before implementation. A review was planned after 6 weeks of use. <h3>Measurement of improvement</h3> We analysed a random selection of 50 entries from each system (total 100). The new system was shown to be superior with 46 (92%) of jobs completed (previously 62%), with 32 (64%) of total jobs acted upon within 24 h of results becoming available (previously 18%) (Figure 1). <h3>Effects of changes</h3> There has been a significant improvement in the chasing, actioning and documentation of results, including dates and timings which improved patient care and experience. The team has improved ownership, traceability and accountability of clinicians who have entered and completed tasks. This encourages and reinforces a culture of teamwork to meet common goals. The few results unavailable on the date expected are now routinely entered for chasing on an appropriate future date to ensure completion. The new system acts as a record for future reference, audit or monitoring. <h3>Lessons learnt</h3> Liaising with a wide variety of MDT colleagues of all grades and utilising a variety of appropriate communication methods were essential for successful system change. <h3>Message for others</h3> We have proven that a relatively simple change in working can significantly improve patient care and foster good team working. This system is readily replicable and can be implemented in any department to yield similar results.

G111 Impact of transcutaneous billirubinometer testing on babies with visible jaundice by community midwives on hospital referrals

Introduction Referrals of newborn babies with jaundice to hospital has emotional and financial impact on parents and increases work load of hospitals. We report results from a service evaluation project looking at the introduction of transcutaneous bilirubinometers (TsB) testing to community midwives using JM 103 TsB as recommended in NICE neonatal jaundice guideline (CG 98). Aim Assess impact of TsB to reduce avoidable hospital referral by community midwifes. Methodology A limited pilot project undertaken in 2013 showed that in the absence of TsB only 40% of babies referred to hospital for neonatal jaundice were admitted. Average waiting time before medical review was 255 min in paediatric assessment units. With innovative project funding from the Welsh Government the project team trained and equipped all 80 community midwives in the Health Board with a TsB each from February 2014. A clear referral pathway was established and activity recorded. Results Data was collected on all babies reviewed by midwives at home for a 6 month period between 01/02/2014 to 31/07/2014 in the Health Board. Compliance of midwifes to protocol was high. 5647 babies were reviewed by midwives, 1046 (19%) were tested with TsB for visible jaundice and 63 (1%) were referred to hospital. Of 48 babies audited 69% of those referred were admitted and 54% received phototherapy. Average waiting time reduced to a quarter at 58 min. Service was given a maximum satisfaction rating by most parents. JM 103 TsB was found to be 100% specific in predicting need for hospital admission (95% CI 78% –100%) and need for phototherapy (95% CI 84.4 –100%). Conclusion Judiciously used TsB can half avoidable hospital referrals and quarter waiting times for babies with neonatal jaundice in first 2 weeks of life. This combined with immediate reassurance and a non invasive pain free test resulted in high parent satisfaction scores. Financial benefits incur to parents from reduced travel costs and to hospitals from reduced blood testing and saved medical time.

G322(P) The development of a paediatric short stay unit

<h3>Aims</h3> There has been pioneering reshaping of our hospital’s ambulatory paediatric services over the last year. In line with the RCPCH report ‘Short Stay Paediatric Assessment Units’, published in 2009, a paediatric short stay unit (PSSU) opened in July 2014, for children needing admission for less than 48 h. It is a consultant delivered service, which aims to meet and exceed the RCPCH ‘Facing the Future’ standards of care. <h3>Methods</h3> Activity data for the first 5 months has been analysed and the impact upon other paediatric services assessed. Patient experience has also been evaluated. <h3>Results</h3> To date, 466 patients have been admitted to PSSU with a median length of stay of 18 h. Elsewhere in the trust, there have been fewer general paediatric bed days (1233) since PSSU opening, compared to 1548 for the same period last year. Since PSSU opening, only 1 patient has been ‘treated and transferred’ to another hospital from PED due to lack of capacity, compared to 10 for the same period last year. Patient satisfaction questionnaires have reported that 76% of families would recommend PSSU to friends and family if they needed similar care or treatment. The comments from patients and their families about PSSU have been overwhelmingly positive (Figure 1). <h3>Conclusion</h3> PSSU has been phenomenally successful in streamlining the patient journey for children requiring hospital admission for less than 48 h. There have been significant secondary gains elsewhere, with reduced numbers of patients needing transfer to other hospitals from PED due to lack of capacity, and increased numbers of inpatient beds for speciality patients. The model of a paediatric short stay unit is here to stay; as was highlighted by ‘Facing the Future’ publication, acute paediatric care should be delivered in a specialised setting, fronted by senior staff who truly believe in the service. This PSSU is one example of this, as a successful expansion of our ambulatory paediatrics service.

G294(P) Only a quarter of children under 5 years have ever taken vitamin d supplements

Aim It has been over a year since the RCPCH circulated interim guidance regarding vitamin D supplements in childhood recommending that breastfed babies from birth and formula fed infants from 6 months should receive vitamin D until 5 years old. Our aim was to assess the percentage of eligible children that take supplements and secondarily vitamin D intake in pregnant and breastfeeding women. Methods We performed a prospective audit in children presenting to the paediatric assessment unit aged from birth up to 5 years from 20/09/14 for 2 months. We recorded: age, ethnic group, gestational age at birth, breastfeeding history, whether patients have taken or taking vitamin D and the indication for that. We also recorded whether the child belonged to a risk group due to prematurity, neurodisability or gastrointestinal problem and whether the child ever presented with seizures due to vitamin D deficiency. Secondary outcomes were percentage of women taking vitamin D supplements during pregnancy and breastfeeding. Results We recruited 158 patients with a mean age of 18 months, 57% were males and 33% were either Afrocarribean or Asian. 15% of the children were at high risk: 13% due to prematurity and 2% due to neurodisability. At the time of the audit only 17% of children were taking vitamin D (image 1) and only 25% had ever taken vitamin D. Of those that were breastfed and less than 6 months 29% were on supplements (image 2); of those older than 6 months only 21% (image 3). Vitamin D was started by parents in 29% and the remaining majority by health professionals. Half of the mothers took vitamin D in pregnancy and only 20% during breastfeeding. Conclusions Despite the circulation of the RCPCH guidelines to paediatricians only a quarter of children under five have ever been on vitamin D. All health care professionals in primary and secondary care should work together towards creating clear and updated policies regarding vitamin D supplements in childhood, pregnancy and lactation, and more work on implementing these policies is needed.

O-181 Vaccine-preventable Disease Susceptibility In A British Paediatric Assessment Unit

Background Although international policy advocates opportunistic immunisation in every clinical setting it is not common practice. Inpatients have lower levels of cover against vaccine-preventable diseases (VPDs) than the community population. Aims To evaluate secondary-care practice before and after introducing simple interventions to improve identification of under-immunised children and facilitate catch-up immunisations. Methods The population-based child health database was used to check immunisation status for two cohorts of 200 consecutive admissions before and after routine printing of immunisation histories from the database and raising staff awareness. VPD susceptibility burdens were calculated for each child. Case notes were assessed for accuracy and documentation of ward-based interventions. Results Fourteen per cent of all (400) children were under-immunised on admission and 27% of these were more than 5 years behind schedule. Under-immunised children’s VPD susceptibility burdens ranged from 0 – 40,858 days and in 59% exceeded 1,000 days. Over one month the paediatric admission unit saw children with a combined VPD susceptibility burden of 1,323 child-years. Positive identification of under-immunised children increased by 40% (95% CI; 12–62, p = 0.002) following the introduction of routine database printouts. This corresponded with a 20% increase in documented actions to encourage catch-up immunisation (95% CI; -1–27, p = 0.026). Catch-up immunisation rates remained low: 0% pre-discharge and 35% in the community at 5 months. Conclusion Children presenting to British secondary care unit have large VPD susceptibility burdens. Positive identification of under-immunised children substantially improved following the introduction of routine database printouts but catch-up immunisation rates did not increase.

Vaccine-preventable disease susceptibility in a British paediatric assessment unit.

Aims: To evaluate practice within a paediatric secondary-care centre before and after introduction of simple interventions to improve identification of under-immunised children and facilitate catch-up immunisations. Methods: The population-based child health database was used to check immunisation status for two cohorts of 200 consecutive admissions before and after routine printing of immunisation histories from the database and raising staff awareness. Vaccine-preventable disease (VPD) susceptibility burdens were calculated for each child. Case notes were assessed for accuracy and documentation of ward-based interventions. Results: Fourteen per cent of all children were under-immunised on admission and 27% of these were more than five years behind schedule. Under-immunised children's VPD susceptibility burdens ranged from 0-40,858 days and in 59% exceeded 1,000 days. Over one month the paediatric admission unit saw children with a combined VPD susceptibility burden of 1,323 child-years. Positive identification of under-immunised children increased by 40% (95% confidence interval: 12-62, p=0.002) following the introduction of routine database printouts. Conclusion: Children presenting to British secondary care units have large VPD susceptibility burdens. Positive identification of under-immunised children substantially improved after the introduction of routine database printouts, but catch-up immunisation rates did not increase.

A 12-year-old Bella Donna

> On a Friday evening, a 12-year-old girl was bought to the paediatric acute assessment unit by her parents. She was complaining of feeling dizzy, shivery and seeing colours. Her...