Discussion on Paediatric Emergency Pathway and Children’s Phlebotomy with Dele Olorunshola, Divisional Director, Women and Child Health, Barking, Havering and Redbridge University Hospitals’ NHS Trust (BHRUT).
Minutes:
1. Children’s phlebotomy Service
Dr Shilsakar confirmed that the children’s phlebotomy service at Queen’s Hospital was available, by appointment, between 8.40 am and 5.10 pm, Monday – Friday. Two full time phlebotomists were available and the service sought to create a child-friendly environment. GPs could access the service but referrals were mostly from special needs schools. Referrals could also come from community paediatricians as well as from outpatients and, to some extent, patients on the hospital wards. The service was designed for children with special needs and behavioural issues.
The service saw up to 50 children per day and waiting times were not more than one working day. The service received good feedback on friends and family scores and play therapists were available to help children and give a good patient experience. Photo guides of procedures were shown to parents and cartoons had been developed to help put children at ease.
It was accepted that the Victoria Hospital did not carry out blood tests for children under 16 years of age and that the busy Queen’s environment could lead to challenging behaviour in children.
Results for routine blood tests were sent to GPs in 1-3 days although this could be longer for more specialised tests.
2. Children’s Emergency Pathway
Dr Equb confirmed that there were paediatric emergency units at both Queen’s and King George Hospitals. The unit at Queen’s saw around 36,000 children per year and King George treated approximately 16,000 children annually. The equivalent annual figure for the Chelsea & Westminster Hospital paediatric emergency unit was 22,000 - 25,000 children treated per year.
A wide range of medical and surgical services were offered at the units. Paediatric emergency medicine clinics, to check on children previously treated, were offered four days a week at Queen’s and one day a week at King George. There were established links with major trauma centres, burns units and other specialist facilities.
The infrastructure of the children’s A & E section had been rebuilt considerably over the past 18 months and the service was now very patient focussed. The unit had been refurbished and there were now separate registration and waiting areas for children.
A clinical nurse was stationed in the waiting area to ensure children did not deteriorate while they were waiting to be seen and cases could be escalated if necessary. Triage staff did checks for the presence of sepsis and also used a safeguarding tool to identify any potential child protection issues.
All clinical guidelines and protocols for children’s A & E had been updated and these were available to junior doctors on-line, via an I-phone app and in paper format. The high staff turnover in the department was being addressed and successful recruitment day in April 2015 had recruited a total of 30 A & E nurses, 10 of whom were paediatric trained. Nurses were rotated between A & E and the children’s ward and there were now full induction packs available for all staff.
A lot of resources had been invested in staff training with sessions arranged for nurses and junior doctors. Specific paediatric nurse training days had also been arranged, led by consultant paediatricians. Formal staff supervision had also increased.
As regards child protection, the safeguarding pathway had been updated and a pathway for dealing with cases of suspected child sexual exploitation had also been introduced. There was also extensive staff training in these areas.
Children exhibiting mental health issues had previously remained in A & E for 24-48 hours. A new pathway for these cases had now been developed however and most cases were now dealt with within six hours. Cases could also be referred to the Child and Adolescent Mental Health Service as needed.
The Care Quality Commission had found that children’s A & E had strong clinical governance. Incidents were investigated and staff involved received regular feedback and supervision. Work was regularly undertaken with the Havering Clinical Commissioning Group on areas such as health promotion sessions and advice booklets for parents.
Children’s A & E met the Royal College quality standards with 96% of patients treated within four hours at King George and 94.8% doing so at Queen’s. The A & E re-attendance rate for children was 1.7% compared to a UK average of 10%. The unit had only received four complaints since the start of 2015, having seen around 28,000 children in that time. The unit was scoring 80-85% on the Friends and Family test at Queen’s (a significant improvement on previously) and 90-95% at King George. There had also been very positive comments received from parents about their children’s treatment etc.
The children’s A & E induction pack was sent to locum agencies and all clinical guidelines were also made available to locum staff. Most locum doctors returned regularly to work in the department in any case. The induction of agency nurses was the responsibility of the matron.
There was a two-month induction period for children’s A & E staff nurses who also only undertook day shifts at first. The clinical director received CVs of locum doctors and reviewed what they had undertaken prior to their commencing work at the unit.
The transition time for children’s A & E cases depended on each individual case. Major burns cases were stabilised and then transferred to Broomfield Hospital. Burns were photographed and e-mailed to Broomfield to enable more accurate treatment to be offered. Once stabilised, children with major trauma were transferred to the Royal London Hospital although most major trauma cases were now taken straight to the Royal London in any case.
Leaflets on domestic violence were placed in the women’s toilets and nursing staff had been trained to ask subtly if a patient needed help. This area was supervised by the Trust safeguarding team. A pathway on this was being worked on and this was part of the child protection assurance group.
A pathway on Female Genital Mutilation (FGM) was also currently being worked on and the Chairman requested that the finalised pathway be brought for scrutiny to a future joint meeting of the Sub-Committees.
If there were major safeguarding concerns then children would not be released home after treatment but this only happened very rarely. Residential social workers from Barking & Dagenham were present in Queen’s A & E and children’s A & E staff met with social workers from all three local boroughs on a weekly basis.
Forms had also been introduced for children to complete as part of the Friends & Family test as well as graphical cards to ascertain what they thought of their treatment etc. It was also hoped to organise listening events with children.
The Community Treatment Team could send children to A & E but cases were usually managed in the community so this only happened rarely.
The Committee noted the position.