Paediatric Assessment Unit Research Articles

G218(P) The Paediatric Sepsis 6 Initiative

Introduction and rationaleSevere sepsis is common in children and the incidence is rising. (estimated prevalence of 0.89/1000 children/year in US population) It is associated with significant morbidity and mortality. Improved...

CORKSCREW 2013 CORK study of children's realistic estimation of weight

BackgroundIn a resuscitation situation involving a child (age 1–15 years) it is crucial to obtain a weight as most interventions and management depend on it. The APLS formula, ‘2×(age+4)’, is...

G144(P) A Study of the Pattern of Attendance and Parent Satisfaction in a Paediatric Assessment Unit

AimsIn many UK hospitals, the Paediatric Assessment Unit (PAU) is part of the acute paediatric ward setting that receives acutely unwell children referred from a number of sources. This study...

G131(P) The Effect of Consultant Delivered Services on Patient Care in Paediatric Assessment Unit

AimTo look at the effect of the consultant delivered care in comparison to the registrar delivered care on the clinical services, patient care, satisfaction and staff opinion.MethodAll the patients attending...

G235 What Did the Doctor Say? Measuring Information Decay in a Paediatric Assessment Unit

AimsAs medicine becomes more complex, the need for effective communication increases. Changes in acute paediatrics have reduced opportunities for information transfer, with more Paediatric Assessment Units (PAU’s) attendances and shorter...

G248(P) Can a Combined Tool with Paediatric Illness Severity Assessment and Paediatric Early Warning Score Be Used as a Safety Tool For Discharge of Patients from Observation and Assessment Unit?

AimOur aim was to evaluate if Paediatric Illness Severity Assessment (PISA) and PEWS can be used as a combined tool for safe discharge of patients from Paediatric Observation and Assessment...

G129(P) Can a Combined Tool with Paediatric Illness Severity Assessment and Paediatric Early Warning Score Be Used as a Safe Tool For Discharge of Patients from Observation and Assessment Unit?

AimOur aim is to evaluate if Paediatric Illness Severity Assessment (PISA) and PEWS can be used as a combined tool for safe discharge of patients from Paediatric Observation and Assessment...

G245(P) Pitfalls in Weight Estimation

Children and infants of different age and weight respond differently to drugs. Special care is needed in the calculation of drug doses to reduce and prevent the risk of toxicity....

Discharge summaries on a Paediatric Assessment Unit (PAU): how accurate are the medications on discharge when there has been no pharmacy involvement?

IntroductionThe Paediatric Assessment Unit (PAU) sees approximately 600 patients each month with about three quarters being seen out of hours, (17:00–08:00 and weekends). During pharmacy hours, (08:30–17:00), the standard procedure...

Uncommon presentation of common problem: pneumomediastinum in a child with diabetic ketoacidosis

A 12-year-old girl, a known patient with type 1 diabetes mellitus, presented to our paediatric assessment unit with short history of vomiting. She was tachycardic, tachypnoeic and normotensive (117/71) on admission. Her blood sugar was high (26.7 mmol/L) with raised blood ketones and her venous blood gas showed metabolic acidosis with high base deficit confirming DKA. HbA1C was very high (99 mmol/mol). The management of DKA was initiated using the Southwest regional paediatric DKA protocol. Due to significant respiratory distress she underwent a chest radiograph, which revealed pneumomediastinum with no pneumothorax (figure 1). Clinical examination showed no evidence of subcutaneous emphysema and her breathing improved after correction of acidosis. The patient was observed closely and was kept nil by mouth. Repeat chest radiograph after 8 hours (figure 2) showed spontaneous resolution of mediastinal emphysema.

Using routinely collected data to improve immunisation histories.

Immunisation is one of the most effective health interventions in existence yet outbreaks of vaccine-preventable diseases continue to occur in developed countries. High rates of cover are needed to provide adequate herd immunity and there is evidence that a significant proportion of paediatric inpatients are not up to date even in areas with high levels of community cover. A proportion of these children will have parents who consciously declined immunisation, however the remaining children represent a vulnerable cohort whose under-immunisation is not routinely identified.Two-hundred consecutive admissions to rural paediatric assessment unit had their routinely documented vaccination histories checked against their records on the regional Child Health Information System (CHIS). 30 children (15%) were not up to date on the CHIS, yet routine clerking only identified 5 of these children (17%). After introduction of a simple system whereby ward clerks and doctors were taught how to access and print full immunisation histories from the CHIS, a further 200 consecutive admissions were audited. A similar number were not up to date (29/200) but the proportion of children with missing immunisations correctly identified in the clerking documentation increased to 52% (15 children). This is a 35% improvement (95% CI; 12–58%).Access to routinely collected data can significantly improve identification of under-immunised children and contribute towards higher levels of individual and herd-immunity.

Review of a nurse practitioner led short stay unit

To review the function of a novel paediatric nurse practitioner (PNP) led short stay assessment unit. A prospective observational study of acute attendances to this unit over 1 year, with 4 one-month data collection periods. Outcomes evaluated included: length of stay, diagnoses, discharges, transfers to the offsite inpatient paediatric ward and re-attendance rates. 270 acute attendances (mean age of 5 years, 23% < 1 year) and a further 107 patients for planned reviews/investigations were seen. The majority (65%) of acute patients spent less than 8 hours on the unit with a discharge rate of 76% and re-attendance of 3%. No significant differences were found in discharge or re-attendance rates for patients seen by PNPs compared to doctors (75% vs 78%, p = 0.66; 1.9% vs 4.4% p = 0.29 respectively). A predominantly PNP-led short stay paediatric assessment unit, with appropriate multidisciplinary support may be a viable and safe option.

Derivation and validation of age and temperature specific reference values and centile charts to predict lower respiratory tract infection in children with fever: prospective observational study

Objectives To develop reference values and centile charts for respiratory rate based on age and body temperature, and to determine how well these reference values can predict the presence of...

Primary care of children: the unique role of GPs

![][1] The provision of medical care for children and young people is changing. Access to GPs has reduced since 2004 due to changes in out-of-hours care. In-hours, the Quality and Outcomes Framework (QOF) has shifted priorities away from providing care for children. Few childhood conditions fall inside the QOF, and consultation rates have increased for all age groups except children.1 Most parents prefer to see their own GP but accept that out of hours this may no longer be possible. Yet out-of-hours services are no substitute for GP care, often directing parents to seek several consultations for the same problem,2 costing families time, money, and increasing anxiety, and potentially introducing delay in diagnosing and treating serious illness. This has impacted on paediatric services in hospital accident and emergency departments which are already stretched and under pressure to achieve waiting time targets, resulting in increased inappropriate short stays in hospital. One in four children aged under 18 years (3 million) attend emergency departments each year;3 short stay admissions (less than 48 hours) have increased by over 40% in a decade.4 At the same time acute paediatrics is changing very fast, with the emergence of Paediatric Assessment Units, a new model for paediatric community services open for 18–24 hours, potentially almost completely replacing … [1]: /embed/graphic-1.gif

The impact of alcohol on conscious level in children and young people

Aims Recent published data from industrialised countries suggests an increase in prevalence of young children and adolescents presenting to hospital with alcohol intoxication. The aim of this abstract is to present the findings of the children and young people presenting to hospital with a decreased conscious level secondary to alcohol intoxication reported in the Decreased Conscious Level Multi-site Audit. Methods 51 NHS trusts collected data on consecutive cases of children less than 18 years who presented to the emergency department or paediatric assessment unit with a decreased conscious level between the period: 1 November 2010 to 30 September 2011. These trusts used either a wholly retrospective or a combined prospective/retrospective approach to identify the cases. Data was collected on 1132 eligible cases of which 315 presented with a decreased conscious level secondary to alcohol intoxication. Results All 315 cases of alcohol intoxication were included. The majority of these cases presented on a weekend (194/315, 61.6%) as compared to a week-day (121/315, 38.4%). The mean age at presentation is 14.7 years (standard deviation= 1.6 years). The median age is 15 years. There were slightly higher numbers of female (172/315, 54.6%) as compared to male cases (143/315, 45.4%). 3/315 (1.0%) were intubated. All cases had either AVPU or GCS used to assess their conscious level. In the 288/315 cases who had GCS performed the mean GCS was 11 (standard deviation = 3) and the median was 13. 55/288 (19.1%) cases had a GCS of 8 or less at presentation (table 1). In 128/315 (40.6%) cases, the child or young person was reviewed by either a consultant or a doctor of ST4 grade or higher. The majority of the cases were discharged home (223/315, 70.8%) while the remainder were either transferred to the ward (85/315, 27.0%), transferred to PICU (3/315, 1.0%) or self-discharged (3/315, 1.0%). Conclusions There is a significant risk of developing coma in young people presenting with alcohol intoxication. Diagnosis of alcohol intoxication should be considered for older children and adolescents presenting to Emergency departments with reduced conscious level.

Characteristics of children and young people presenting acutely with a decreased conscious level (multi-site audit 2010-2011)

<h3>Aim</h3> To describe the characteristics of children and young people presenting to hospital with reduced consciousness reported in the Decreased Conscious Level Multi-site Audit. <h3>Methods</h3> 51 NHS trusts collected data on consecutive cases of children less than 18 years who presented to their emergency department or paediatric assessment unit with a decreased conscious level between the period: 1 November 2010 to 30 September 2011. The cases were identified using either a retrospective or a combined prospective/retrospective approach. Data was collected on 1147 cases, of which 1132 met the audit9s inclusion criteria. <h3>Results</h3> The mean age at presentation was 8.3 years (standard deviation = 6.3 years) with a median age of 8 years (table 2). There were 620/1132 (54.7%) males and 512/1132 (45.2%) females reported. 1096/1132 (96.8%) cases had either AVPU or GCS (Glasgow Coma Scale) used to assess their conscious level. In the 900 cases who had GCS performed, the mean GCS was 11 (standard deviation = 4) and the median was 13. 203/900 (22.6%) cases had a GCS of 8 or less at presentation (table 1) and a total of 176/1132 (15.5%) required intubation. The most common working diagnoses among the cases were alcohol intoxication (311/1132, 27.5%), infective causes (217/1132, 19.2%), trauma (176/1132, 15.6%) and febrile seizure (117/1132, 10.3%). 61.0% (690/1132) cases were reviewed by either a consultant or a doctor of ST4 grade or above in paediatrics or emergency medicine. There were 16 (1.4%) deaths among the 1132 cases. The reminder of the cases were either discharged home (470/1132, 41.5%), transferred to the ward (478/1132, 42.2%), transferred to PICU (111/1132, 9.8%) or transferred to another hospital for acute services (46/1132, 4.1%). <h3>Conclusions</h3> Decreased conscious level is a multi-factorial condition affecting children and young people of all ages. A significant proportion of these children will require resuscitation and ongoing care in hospital.

The atraumatic limping child – does a pathway improve assessment of limping children seen in a DGH acute paediatric assessment unit PAU?

<h3>Aims</h3> A new pathway for assessing limping children was introduced and audited in a DGH PAU. It offers a decision making tree for investigations based on “red flags” and systemic illness features. The intention was to assess pathway suitability and management choices and make comparisons to previous local audits. <h3>Method</h3> After the pathway was advertised and introduced, a retrospective case note review was conducted. Children logged in the attendance diary as limp/non weight bearing/leg pain were analysed for 6 months following pathway introduction. Their notes were retrieved and assessed alongside a standardised data collection form. The audited standard was 100% use of the limping child pathway. <h3>Results</h3> 29 relevant children aged 8 months to 13 years were identified. Fewer blood tests and xrays performed, fewer children required orthopaedic opinions and follow up was consistently earlier (48-72 hrs, better safety-netting) compared to pre-pathway audits. Pathway was used in 32%. Clerkings reconsidered during audit to decide which investigations the auditor would have requested; actual investigations done were thus labelled “good” or “bad” decisions. Pathway use improved decision making – good decisions increased from 73% to 86%; bad decisions decreased from 27% to 14%. <h3>Conclusion</h3> Improvements following previous audits attributed both to direct pathway use and raised awareness of limping assessment in other cases. Based on this small audit, the pathway lead to a more standardised assessment and streamlining of visits. The 100% target for pathway uptake was not met but based on this audit, it helped practitioners rationalise investigation choices safely and improved confidence in reviewing and discharging children. Ongoing local work has produced a policy for limping children, which will be accessible to related users (Paediatrics, A&amp;E, Orthopaedics) and aims to improve local cross departmental practise. National practice remains variable and we believe there is a need for national evidence based guidance.

Nurse practitioner led short stay assessment units: an alternative model of care?

Aim The UK is undergoing a major reconfiguration of inpatient paediatric services. Recent guidelines encourage the development of short stay assessment units to increase patient/parent satisfaction and reduce burden on inpatient care. We wish to evaluate a novel 24-hour assessment unit whereby Paediatric Nurse Practitioners (PNPs) take the lead role in assessment and management with additional support provided by doctors. Methods A prospective observational study of acute attendances to this short-stay assessment unit over four data collection periods was performed. Each period lasted one month and each season was included. Outcomes evaluated included: reason for attendance, length of stay, discharges, transfers to the offsite inpatient paediatric ward and re-attendance rates. Results 270 acute attendances (mean age of 5 years, 23% Conclusion The data analysed are comparable to standard doctor-led units reported in the literature and would suggest that this model of care, with appropriate doctor involvement, could be a safe option for a short stay paediatric assessment unit. However to further determine the viability of such a unit, further research is recommended to ascertain cost-effectiveness and parent/staff satisfaction.

Children’s experiences of acute hospitalisation to a paediatric emergency and assessment unit – A qualitative study

Short-stay treatment has become a popular form of care as a strategy to cope with increased demands on health care. There is little research that considers children's experiences of acute hospitalisation to a short-stay care facility such as a Paediatric Emergency and Assessment Unit (PEAU). This study explored the experiences of eight children aged 8-10 years. Semi-structured interviews were carried out to investigate the children's own experiences of being hospitalised in a PEAU. Thematic content analyses were used. Three major themes were identified: the children's understanding of disease, treatment and procedures; the children's experiences of health-care personnel and the PEAU and transformation of everyday life into the settings of the hospital. The children identified the hospital stay as an overall positive experience. The children took part in leisure activities as they would at home and enjoyed time together with their parents while in hospital. In their conversations with staff they adapted to professional terms that they did not necessarily understand. They did not differentiate between professionals. Further work should be considered to clarify the consequences of this. This study has provided some limited insight into the child's experiences of acute hospitalisation, which should inform nursing care.

030 Multi-centre study of the emergency management of allergic reactions and anaphylaxis

Objectives and BackgroundThe Royal College of Paediatrics and Child Health (RCPCH) recently published its care pathway for anaphylaxis incorporating an algorithm with the stages of ideal care and a set...