Children & Young People Acute Care PathwaysDr Tim Fooks, GP and Clinical LeadSEC SCN Children and Young People
UK Mortality Rate
If the UK health system performed as well as that of Sweden, as many as 1500 children might not die each
year.
Children & Young People Strategic Clinical Network
CYP Work Programme
Children and young people emergency and urgent care pathway
Parents/CarersSelf HelpInternet
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Care
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* Minor illness, Minor Injury Unit ** Child and Adolescent Mental Health Service
Self Referral
Referral from the community
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Children, Young People and Families
Commissioners
This Whole System
approach applies across all CYP areas
with collaboration
key
5
Right place, right time ....?
High Volume ConditionsAdmission Data
FeverD&V
Bron'litisHead Injury
0
500
1000
1500
2000
2500
CWS
B&H
Crawley
CWSB&HCrawley
Admissions with No LOS for children <5yr 2013/4
In most CCGs, up to 50% are the target group
Keeping Sick Kids Safe
Role of the Clinician
Role of the Clinician for parents
• Recognition of serious illness
• Reassurance
• Resilience promotion
• Factors affecting parents seeking help from medical services:• Sense of responsibility + fear of failure
• Felt or enacted criticism by professional
• Failure to be reassured: • “Viral” explanation seen as sign of medical
uncertainty
• Inconsistent approach by Clinicians
Accessing Care - Parents with Sick Children
The Goldilocks Zone
Acute Care Pathways
60 Second Practice Survey• >80% response• 91% aware of pathways• Usage – sometimes• Advice sheets – sometimes• 82% Pulse sat monitor suitable for children
<5yr
16
GP Quotes• “Personally I found them very useful
providing a clear concise and reassuring checklist”
• “I feel much safer handling bronchiolitis patients than I have done in the last 25 years”
17
• Fever, D&V and Bronchiolitis
• Dr Nelly Ninis, Consultant Paediatrician, St Mary’s, Paddington.
• Expert in diagnosis of septicaemia• Member of NICE guideline panel
• Available NOW at e-LfH
e-learning module (HEKSS)
Fever
Acute Care Pathways
• normal part of childhood illness, • ~ 70% of preschool children yearly.• ~ ½ taken to health professional • Probably important component of immune response • Use of antipyretics is widespread. • reasons for treating fever are contested and not
necessarily evidence based but include minimising discomfort, controlling the fever, and preventing febrile convulsions.
• May be a component of early serious disease
Fever
• Definition of threshold for fever• 81% <38.0°C, (100.5°F)• 0% between 38.0°C and 38.3°C, • 19% >38.3°C. (101°F)
• 20% children brought to clinic for a chief complaint of fever were never truly febrile.
• 93% participants believed that high fever can cause brain damage.
• For a comfortable-appearing child with fever, • 89% of caregivers would give antipyretics• 86% would schedule a clinic visit.
Fever Literacy and Phobia
• Consideration of sepsis associated with faster onset of treatment
• Delay in antimicrobial Rx associated with hour by hour worsening of outcome
• Only 50% of neonatal cases of meningitis (<3m) present with fever, but do have other features of serious illness (poor feeding, lethargy and poor overall state)
Pre-hospital Recognition of Serious Illness
• 448 children and young people ,16yr• 103 fatal, 345 non-fatal• Micro confirmation 373 cases
Recognition of Meningococcal Disease
• 4-6hr - non-specific symptoms• 8hr (median time) – 72% signs of early sepsis
(leg pains, cold hands and feet, abnormal skin colour)
• 24hr – most close to death • 50% admitted after first consultation• 19hr – median time to hospital admission• 13-22hr – median onset of classic features
(haemorrhagic rash, meninigism, impaired consciousness)
Recognition of Meningococcal Disease
Parent Advice Sheets
NICE CG 160 Fever – key messages
A. Thermometers and the detection of fever In children aged 4 weeks to 5 years, measure body temperature by one of the following methods: 1. electronic thermometer in the axilla 2. chemical dot thermometer in the axilla 3. infra-red tympanic thermometer. [2007] B. Reported parental perception of a fever should be considered valid and taken seriously by healthcare professionals. [2007]
NICE CG 160 Fever – key messages
C. Clinical assessment of the child with fever
Assess children with feverish illness for the presence or absence of symptoms
and signs that can be used to predict the risk of serious illness using the traffic
light system [2013]
Measure and record temperature, heart rate, respiratory rate and capillary refill
time as part of the routine assessment of a child with fever. [2007]
NICE CG 160 Fever – key messages
D. Recognise that children with tachycardia are in at least an intermediate-risk group for serious illness. Use the Advanced Paediatric Life Support (APLS)[1] criteria below to define tachycardia: [new 2013] Age Heart rate (bpm) <12 months >16012–24 months >1502–5 years >140 E. Management by remote assessment Children with any 'red' features but who are not considered to have an immediately life-threatening illness should be urgently assessed by a healthcare professional in a face-to-face setting within 2 hours. [2007]
NICE CG 160 Fever – key messages E. Management by the non-paediatric practitioner If any 'amber' features are present and no diagnosis has been reached, provide parents or carers with a 'safety net' or refer to specialist paediatric care for further assessment. The safety net should be 1 or more of the following: 1. providing the parent or carer with verbal and/or written information on warning symptoms and how further healthcare can be accessed (see section 1.7.2) 2. arranging further follow-up at a specified time and place 3. liaising with other healthcare professionals, including out-of-hours providers, to ensure direct access for the child if further assessment is required. [2007] 013]
NICE CG 160 Fever – key messages
F. Management by the paediatric specialist Perform the following investigations in infants younger than 3 months with fever: full blood countblood cultureC-reactive proteinurine testing for urinary tract infection[2]chest X-ray only if respiratory signs are presentstool culture, if diarrhoea is present. [2013]
NICE CG 160 Fever – key messages
G. Antipyretic interventions• Antipyretic agents do not prevent febrile convulsions and
should not be used specifically for this purpose. [2007]• No place for tepid sponging• Do not underdress or overwrap
H. When using paracetamol or ibuprofen in children with fever;• continue only as long as the child appears distressed• consider changing to the other agent if the child's distress is not alleviated• only consider alternating these agents if the distress persists or recurs before
the next dose is due. [new 2013]• do not give both agents simultaneously
Paracetamol or Ibuprofen or Both
Ibuprofen Paracetamol Both I+P0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
Reporting Odds Ratio - Acute Kidney Injury risk in <12yr
Yue Z1, et al 2014
ROR
Paracetamol or Ibuprofen or both?
• Safety profiles when used alone similar but underlying health issues need to be considered
• Ibuprofen is more effective than paracetamol• has faster onset of action & lasts longer
• relieving fever-associated discomfort, • providing symptom relief • improving general behaviour
• Selecting the most suitable antipyretic for the individual child may help to optimize the chance of treatment success first time, thereby limiting the need to administer further treatment
• Drugs R D. Jun 2014; 14(2): 45–55. Published online Jun 12, 2014. doi: 10.1007/s40268-014-0052-x PMCID: PMC4070461 A Practical Approach to the Treatment of Low-Risk Childhood Fever Dipak Kanabar
Paracetamol or Ibuprofen or both?
• Children under 3 months• Varicella zoster infection
• (NSAIDs linked to increased risk of severe cutaneous complications in VZV infection)
• Known aspirin sensitivity • (2% asthmatic prone to exacerbation with ibuprofen, + another 2% have drop
in spirometry), but in those who are not NSAID sensitive, ibuprofen reduces risk of asthma exacerbation more than paracetamol)
• Pre-existing renal failure ie marked dehydration• Multi-organ failure • Risk of GI bleed
When to use Paracetamol
• 30mg/kg in 24 hours in divided doses
• 3-6 months: 50 mg (2.5 ml) 3 times daily.• 6-12 months: 50 mg (2.5 ml) 3 or 4 times daily.• 1-4 years: 100 mg (5 ml) 3 times daily.• 4-7 years: 150 mg (7.5 ml) 3 times daily.• 7-10 years: 200 mg (10 ml) 3 times daily.• 10-12 years: 300 mg (15ml) 3 times daily.
Ibuprofen dose?
• Single dose 10–15 mg/kg
• 4 times daily regimen - max 60mg/kg/24hrs
• Suspension (120mg/5ml) daily dose
• No. of 5ml tspns in 24 hour period = wt(kg) x 0.5
Paracetamol dose?
Paracetamol or Ibuprofen or Both
The PITCH Study Conclusion “Parents, nurses, pharmacists, and doctors wanting to use medicines to supplement physical measures to maximise the time that children spend without fever should use ibuprofen first and consider the relative benefits and risks of using paracetamol plus ibuprofen over 24 hours.” BMJ 2008;337:a1302
Role of the Clinician• Recognition of serious
illness • Reassurance and
Resilience promotion of parents and carers
• Respond in timely fashion
• Record clinical findings
Diarrhoea & VomitingAcute Care Pathways
DiagnosisPerform stool microbiological investigations if:• you suspect septicaemia or• there is blood and/or mucus in the stool or• the child is immunocompromised.
NICE CG 84 D&V – key messages
Fluid managementIn children with gastroenteritis but without clinical
dehydration:• continue breastfeeding and other milk feeds• encourage fluid intake• discourage the drinking of fruit juices and carbonated
drinks, especially in those at increased risk of dehydration (see 1.2.1.2)
• offer oral rehydration salt (ORS) solution as supplemental fluid to those at increased risk of dehydration (see 1.2.1.2).
NICE CG 84 D&V – key messages
Nutritional managementAfter rehydration:• give full-strength milk straight away• reintroduce the child's usual solid food• avoid giving fruit juices and carbonated
drinks until the diarrhoea has stopped.
NICE CG 84 D&V – key messages
Information and advice for parents and carersAdvise parents, carers and children that[4]:• washing hands with soap (liquid if possible) in warm
running water and careful drying is the most important factor in preventing the spread of gastroenteritis
• hands should be washed after going to the toilet (children) or changing nappies (parents/carers) and before preparing, serving or eating food
• towels used by infected children should not be shared
NICE CG 84 D&V – key messages
Information and advice for parents and carers• children should not attend any school or other
childcare facility while they have diarrhoea or vomiting caused by gastroenteritis
• children should not go back to their school or other childcare facility until at least 48 hours after the last episode of diarrhoea or vomiting
• children should not swim in swimming pools for 2 weeks after the last episode of diarrhoea.
NICE CG 84 D&V – key messages
Bronchiolitis
Acute Care Pathways
Consider in an infant with • nasal discharge • wheezy cough• fine inspiratory crackles and/or • high pitched expiratory wheeze• apnoea may be a presenting feature
SIGN 91 - Diagnosis of Bronchiolitis
Seasonality
• Prematurity (<35 weeks)• Congenital Heart Disease• Chronic Lung Disease of Prematurity• Parental Smoking• (Social Deprivation)
• Protective factor – Breast feeding
Significant Co-Morbidities
• Antivirals – not recommended • Antibiotics – not recommended • Beta-2 agonists – not recommended • Anti-cholingerics – not recommended • Nebulised ephedrine – not recommended • Inhaled corticosteroids – not recommended• Oral corticosteroids – not recommended• LTRA - not recommended • Chest physio – not recommended (unless on PICU)• NG suction, Oxygen therapy, Ventilation – should be
considered
Treatment options
Head Injury
Acute Care Pathways
Take head injuries seriously, says NICE
• 1.4 million people attend A&E in England and Wales each year with a recent head injury. Up to 700,000 of them will be children under the age of 15.
• Head injury is the most common cause of death and disability in people up to the age of 40.
• Early detection and prompt treatment is vital to save lives and minimise risk of disability, says updated guidance from the National Institute for Health and Care Excellence (NICE).
NICE CG 16 Head Injury
PAEDIATRIC HEAD INJURIES
Dr Helen MilneEmergency Medicine Consultant
Worthing Hospital
Head injury data 2011Head Injury Presentations
Total Paeds Attendances
% Total ED Attendances
% PaedsED Attendances
Worthing 2157<16 years
16,033<19 years
23% 10-15%
SRH 1703 ~14,930 ~25% ~11-12%
Age of patients
050
100150200250300350400
<1
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
WorthingSRH
Outcome
0
500
1000
1500
2000
2500
discharged admitted did not wait
WorthingSRH
Data Review< 5 years Admissions CT Abnormal
CTNeurosurgical
Worthing 56.5% 4.5% 0.8% 0.2% ?1 patient
SRH 55.7% 8.1% 1.5% 0.2% 1 patient
CHALICE(22,772)
56% 6.4% 3.3% 1.2% 0.6%
Key PointsMost head injuries seen in the ED – • Could be managed with observation at home
• Few need admitted
• Rare to need a CT scan
• Even more rare to need neurosurgery
Likelihood of brain injury increased by -• LOC
• Mechanism of injury
• GCS
Children’s brain injuries• Most non surgical treatment
CT scan radiation• 100-200 chest x-rays
As soon after event as possible [1]• Unconsciousness or lack of full consciousness, even if
the person has now recovered.• Any clear fluid running from the ears or nose.• Bleeding from one or both ears.• Bruising behind one or both ears.• Any signs of skull damage or a penetrating head injury.• The injury was caused by a forceful blow to the head at
speed (for example, a pedestrian hit by a car, a car or bicycle crash, a diving accident, a fall of 1 metre or more, or a fall down more than 5 stairs).
NICE CG 176: Head Injury – when to go to hospital
As soon after event as possible [2] • The person has had previous brain surgery.• The person has had previous problems with
uncontrollable bleeding or a blood clotting disorder, or is taking a drug that may cause bleeding problems (for example, warfarin).
• The person is intoxicated by drugs or alcohol.• There are safeguarding concerns, for example about
possible non-accidental injury or because a vulnerable person is affected
NICE CG 176: Head Injury – when to go to hospital
If any of the following develop subsequently Problems understanding, speaking, reading or writing.• Loss of feeling in part of the body or problems with balancing or
walking.• General weakness.• Changes in eyesight.• A seizure (also known as a convulsion or fit).• Problems with memory of events before or after the injury.• A headache that won't go away.• Any vomiting.• Irritability or altered behaviour such as being easily distracted, not
themselves, no concentration, or no interest in things around them. This is particularly important in babies and children under 5.
NICE CG 176: Head Injury – When to go to hospital
Acute Asthma
Acute Care Pathways
National Review of Asthma DeathsConfidential Enquiry – reported 2014
• Review of all deaths from Feb 2012 to January 2013 where asthma was listed in part 1 or 2 of the death certificate
• 3544 death certificates reviewed, 2644 excluded as either over 75 or asthma not thought to be cause of death
• 900 deaths included• After data review 195 deaths thought to be from
asthma• 80 male, 115 female
Paediatric data• 40 (of 195) children identified
– 12 cases no data returned therefore only 28 paediatric deaths reviewed
• 28 under 19 years– 10 under 10 years– 18 aged 10 – 19 years
• 12 though to have mild / moderate asthma• 4 had PAAP (Personal Asthma Action Plan)• Most died before reaching hospital• 4 known to social services
Key recommendations – all ages• All patients prescribed more than 12 short acting reliever
inhalers in previous 12 months must be reviewed urgently• Assessment of inhaler technique should be done at every
asthma review. This should be checked by the pharmacist for any new device
• Use of combination inhalers is encouraged• Monitor adherence• Electronic surveillance of prescribing should be introduced
as a matter or urgency• Document smoking / smoke exposure, and • refer current smokers or carers to smoking cessation
service
Red flags• Excessive beta agonist use• Poor adherence to preventer treatment• Long acting beta agonist (LABA) as
monotherapy• Lack of PAAP• Poor perception of worsening symptoms
Key recommendation - children• Parents and children, and those who care for or teach
them, should be educated about managing asthma.
• To include • ‘how’, ‘why’ and ‘when’ to use asthma medications, • recognising when asthma is not controlled• knowing when and how to seek emergency advice
• Emphasise minimising exposure to allergens and second hand smoke, especially in young people with asthma
Personal Asthma Action Plan
Other Resources
e-LfH Learning Module
Spotting the Sick Child
Short Film for parents and carers