ROYAL FREE LONDON NHS FOUNDATION TRUSTCHILDREN SERVICES GUIDELINES

Diarrhoea and Vomiting Guideline for Children, Nurse-led

Assessment and Criteria-based Discharge Pathway(Cross site RFH & BH guideline)

Author(s): Rinal Desai, Senior Paediatric SisterSamantha Milton, Junior Paediatric Sister

Contact author: Rinal Desai, Senior Paediatric Sister

Other contributors: N/A

Previous authors: N/A

Related guidelines or documents:

NICE guideline- Diarrhoea and vomiting for children caused

by gastroenteritis: Diagnosis, assessment and management

of children younger than 5yrs (2009)

Approved by/date: The Paediatrics Guidelines Group on behalf of the Women,

Children and Imaging Services Division

Issue no (Version): September 2015 (version no. 1.0)

File name: Diarrhoea and Vomiting Guideline for Children, Nurse-led Assessment and Criteria-based Discharge Pathway

Key words: (up to 10) Gastroenteritis, dehydration,

Supercedes: N/A

Significant change in practice:

New guideline

Stakeholders consulted Krishna Jada; Paediatrics

Target clinical audience Paediatrics; Paediatric Emergency Department: Paediatric nurses; ED doctors.UCC: Emergency Nurse Practitioners, UCC GP

Implementation and launch plan:

Upload onto Freenet, and publicising through newsletters

and Paediatrics team meetings

Audit/monitoring plan See Appendix One

Service Line Lead Paediatrics: Rahul ChodhariClinical Director Tim WickhamDirector of Midwifery Mai Buckley

Date for review: September 2019 or in response to practice developments

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ContentsIntroduction....................................................................................................................3Guideline........................................................................................................................3Assessing dehydration and shock in children................................................................8Nurse-led discharge........................................................................................................9Parents fluid challenge sheet........................................................................................10Children’s ED / Paediatric Services (Parent or Carer).................................................11Summative assessment.................................................................................................15Supervised practice for vomiting and diarrhoea pathway............................................17Monitoring compliance................................................................................................18References....................................................................................................................18EQUALITY STATEMENT.........................................................................................18APPENDIX 1: MONITORING TOOL........................................................................19

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INTRODUCTIONThe purpose of this guideline is to improve the way we manage children with diarrhoea and vomiting in the Paediatric Emergency Department (PED). It will improve the flow of patients through the department and deliver a better experience for children and their parents/guardians. Current practice is that all children presenting with diarrhoea and vomiting are assessed by a nurse initially and then treated by a doctor or Advanced Nurse Practitioner.

The aim of this policy is to develop a nurse led, criteria based assessment and discharge pathway for children whose illness can be safely managed at home. This will shorten the patient’s journey in the PED and enhance clinical practice, helping achieve the targets set out by Reforming Emergency Care. This guideline will also provide greater autonomy for the nurse whilst maintaining clinical standards.

The NICE guideline Diarrhoea and Vomiting diagnosis, assessment and management in children younger than 5 years (April, 2009) states that it can be used by nurses.

Research carried out in our Paediatric Emergency Department calculated the relative risk of serious illness depending on a sample size of 50 patients’ presenting with clinical signs and symptoms of diarrhoea and Vomiting. Based on these findings we have designed a protocol that the assessment nurse will use to discharge patients.

Parent education is paramount to the efficacy of this new pathway. We have produced a Patient education and information leaflet for parents to support the new pathway. These leaflets will be available in the PED and will be published on the trust website.

With any guideline, there will always be a small risk that a seriously unwell child will be missed; however, these will be dealt with on an individual basis and following correct procedures outlined by the Trust for such eventualities. In making clinical decisions the nurse should work within their level of expertise and take advantage of the expertise of all members of the PED team.

GUIDELINEThe purpose of this guideline is to improve satisfaction for children and parents by expediting treatment for this group of patients presenting to the Paediatric Emergency Department. Parents/guardians will be given the option to have the child seen by a doctor at any stage if they would prefer this.

Exclusion Criteria

Infants under 1 years Significant past medical history Re-attendance during the same illness GP referral Passing urine less than three times in 24hrs Any safeguarding concerns Bilious (green) vomit

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Signs of dehydration and shock ( Refer to Appendix A) Haematemesis or blood and/or mucus in stool Non-blanching rash, neck stiffness, photophobia, bulging fontanelle in infants Severe/localised abdominal pain or distension Altered conscious state Shortness of breath or Tachypnoea

History suggestive of gastroenteritis

Acute change in stool consistency and/or onset of vomiting. Duration of symptoms < 10 Days. May be accompanied by fever and other viral symptoms. Infectious contact history.

Children discharged under this guideline must fulfil the following criteria

Normal full set of observations including central capillary refill time. Be alert and orientated. Have moist mucous membranes. First presentation with this illness. Consider checking blood glucose levels in children under the age of 2 years

of age.

Documentation must include the followin g general points:

If you suspect gastroenteritis, ask about:

recent contact with someone with acute diarrhoea and/or vomiting and

exposure to a known source of enteric infection (possibly contaminated water or

food) and

recent travel abroad

Assess Clinical dehydration and shock status ( Appendix A)

Who is accompanying the child? If this is not a parent/guardian document name and details of the temporary carer, the circumstances under which they are caring for the child, and whether the parent is aware of the attendance. Consider contacting the parent if this seems appropriate

Time scale and process of symptom development.

An assessment of GCS or AVPU. For younger children this could also include a description such as “playing happily” or “settled”. Has altered responsiveness e.g. irritable or lethargic

An assessment and documentation of Clinical observations including Heart rate, respiratory rate, central capillary refill time, temperature and PEWS Score Noted

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What advice or instructions have been given to the parent?

5

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Exclusion Criteria For Nurse Led Discharge:

Orange Or Red PEWSCap Refill >3Mottled Infant under 1 yearSignificant past medical history – defined as being under the c/o a hospital paediatricianRe-attendance during the same illnessGP referralPassing urine less than three times in 24hrsAny safeguarding concernsBilious vomitingHaematemesis or blood and/or mucus in stoolNon-blanching rash, neck stiffness, photophobia, bulging fontanelle in infantsSevere/localised abdominal painAltered conscious state

PEWS Score Green or Yellow. Child NOT clinically dehydrated

Commence Oral rehydration (5ml every 5 mins for children <5yrs, 10ml every 5 mins for children >5 years)

Obtain urine sample for children presenting with vomiting only

Reassess after 1hr . Repeat PEWS Score and document amount of fluid tolerated.

Full set of normal observations and fluid rehydration tolerated

Home with parent advice leaflet.

Failed oral rehydration

Deteriorating PEWS Score

Positive Urine Dip (Leucocytes, Nitrites, glucose +/or protein > 1+)

Refer to Doctor/ UCC GP for further assessment

Child presenting with Diarrhoea and Vomiting

The individual nurse’s practice will be assessed by an ED consultant, ED Registrar or a Paediatric Nurse who has completed the physical assessment module at Masters Level. They will be assessed according to competency criteria within a framework of required skills. Any PED nurse who has performed these procedures and is competent may practice under the jurisdiction of this guideline. Junior nurses and those who have had little experience of these procedures may perform them under supervision of a more senior and experienced member of staff until competent to practice alone and unsupervised.

The nurse will be required to complete competencies for enhanced clinical practice as well as the procedure-specific competence for Diarrhoea and Vomiting Guideline and these will be linked to the nurse’s individual Knowledge Skills Framework.

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ASSESSING DEHYDRATION AND SHOCK IN CHILDREN

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Increasing severity of dehydration

No clinically detectable dehydration

Clinical dehydration Clinical shock

Sym

ptom

s (r

emot

e an

d fa

ce-to

-face

as

sess

men

ts)

Appears well Appears to be unwell or deteriorating

–

Alert and responsive Altered responsiveness (for example, irritable, lethargic)

Decreased level of consciousness

Normal urine output Decreased urine output –

Skin colour unchanged Skin colour unchanged Pale or mottled skin

Warm extremities Warm extremities Cold extremities

Sign

s (fa

ce-to

-face

ass

essm

ents

)

Alert and responsive Altered responsiveness (for example, irritable, lethargic)

Decreased level of consciousness

Skin colour unchanged Skin colour unchanged Pale or mottled skin

Warm extremities Warm extremities Cold extremities

Eyes not sunken Sunken eyes –

Moist mucous membranes (except after a drink)

Dry mucous membranes (except for ‘mouth breather')

–

Normal heart rate Tachycardia Tachycardia

Normal breathing pattern Tachypnoea Tachypnoea

Normal peripheral pulses Normal peripheral pulses Weak peripheral pulses

Normal capillary refill time

Normal capillary refill time Prolonged capillary refill time

Normal skin turgor Reduced skin turgor –

Normal blood pressure Normal blood pressure Hypotension (decompensated shock)

Box 1 at increased risk of dehydration: Children younger than 1 year, especially those younger than

6 months infants who were of low birth weight children who have passed six or more diarrhoea stools in the

past 24 hours children who have vomited three times or more in the past

24 hours children who have not been offered or have not been able to

tolerate supplementary fluids before presentation infants who have stopped breastfeeding during the illness Children with signs of malnutrition.

Suspect hypernatraemic dehydration if there are any of the following: jittery movements increased muscle tone hyperreflexia convulsions drowsiness or coma.

Laboratory investigations: Do not routinely perform blood biochemistry. Measure plasma sodium, potassium, urea,

creatinine and glucose concentrations if:Intravenous fluid therapy is required orThere are symptoms or signs suggesting hypernatraemia.

Measure venous blood acid–base status and chloride concentration if shock is suspected or confirmed.

Interpret signs and symptoms taking into account the risk factors for dehydration (see Box 1).More numerous and more pronounced symptoms and signs of clinical dehydration indicate greater severity. For clinical shock one or more of the signs and/or symptoms would be present. Dashes (-) indicate that these clinical feature do not specifically indicate shock. Symptoms and signs with red flags ( ) may help to identify children at increased risk of progression to shock. If in doubt, manage as if there are symtoms and/or signs with red flags. Adapted from ‘Diarrhoea and Vomiting in Children’ (NICE Clinical Guideline 84). The quick reference guide and full guidance are available from www.nice.org.uk/CG84

NURSE-LED DISCHARGEYES / NO COMMENTS

Is the child under 1 year of age?Acting inappropriately for age?Any further episodes of Vomiting?PEWS – Yellow, Orange or Red?Urine Sample provided with positive dip

If ‘No’ is the answer to all questions – Fit for Nurse-Led Discharge

If ‘Yes’ is the answer to at least one of the questions refer to A&E• Observe for at least one hour• Parents given information Leaflet and Red Flag Advice?

Nurse-Led Signature______________________________________________

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PARENTS FLUID CHALLENGE SHEETUNDER 5 YEARS – 5mls every 5 minutesOVER 5 YEARS – 10mls every 5 minutes

(NB if your child vomits please inform a member of staff)

Time Achieved

5 Minutes

10 Minutes

15 Minutes

20 Minutes

25 Minutes

30 Minutes

35 Minutes

40 Minutes

45 Minutes

50 Minutes

55 Minutes

10

1 hour

CHILDREN’S ED / PAEDIATRIC SERVICES (PARENT OR CARER)Please think about the appointments you, your child and / or your family have had with the Children’s ED/ Paediatric Services with regards to Nurse Led DischargeFor each item, please tick the box that best describes what you think or feel about the Children’s ED/ Paediatric Services (e.g. ).

NLD for Gastroenteritis NLD for Minor Head Injuries

Certainly True

Partly True

Not True

Don’t know

If a friend needed similar help, I would recommend that he/she are seen by the paediatric nurse and provided with nurses Led assessment and discharge

? 01

It was easy to talk to the people who have seen my child ? 02

I was treated well by the people who have seen my child ? 03

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My views and worries were taken seriously ? 04

I feel that the Nurse who assessed my child listened to me ? 05

I have been given enough explanation about my child’s diagnosis and a sufficient discharge advise leaflet and explanation

? 06

I feel that the people who have seen my child are working together to help with the problem(s)

? 07

We were seen within the 4 hour waiting time ? 08

I feel the people from the Children’s ED/ Paediatric Services know how to help with the problem I am experiencing

? 09

Overall, the help I have received from the Children’s ED/ Paediatric Services is good ? 10

What was really good about your care and the Nurse Led Discharge Pathway?.....13

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Was there anything you didn’t like or anything that needs improving? ........................14

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Is there anything else you want to tell us about the service you received? ...............15

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Optional information:Child’s age: .................................Child’s gender: Female Male Child’s ethnicity: White Black / Black British Asian /Asian British

Mixed Other …………………………..

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Is your child registered disabled (e.g. hearing-impaired)? No Yes

If you don’t want to take part, please tick this box and return the blank questionnaire.

THANK YOU FOR YOUR HELP

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SUMMATIVE ASSESSMENTCOMPETENCE for (ENHANCED) CLINICAL PRACTICE - SUMMATIVE ASSESSMENT.

Vomiting and Diarrhoea Guideline for Children – Nurse led assessment and criteria based discharge pathway

Name: ……………………………….. Date of Assessment: ……………………………….

Area of Practice: ………………………………………………..

To obtain a pass the candidate MUST meet 'Independent' Competency for all the following performance criteria. In the event of this not being achieved then the candidate must be reassessed at a negotiated later date. Competencies MUST be reassessed annually.Evidence MUST be produced for each of the performance criteria. Evidence may include reflective statements, comments by colleagues, appraisal documentation, copies of educational packages produced by the individual, audits, and certificates of attendance, direct observation and questioning. The nurse needs to complete five supervised discharges before they can practice this pathway autonomously.

Performance Criteria Evaluation Method Evidence Produced Competency Level Pass or Refer Review date

1. Accurate interpretation & understanding of the Pathway.

Direct questioningObservation

2.Takes into account child protection issues at all times, making referrals as appropriate.

Direct questioningObservation

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3.Demonstrates the ability to elicit history from the child/parent/caregiver and accurately document the assessment made, care provided and advice given in the appropriate care record.

Direct questioningObservation

`

4. Can identify signs/symptoms that would necessitate management outside these procedures. Awareness of Red Flags.

Direct questioningObservation

5. Acts at all times to keep child and family well-informed, causing minimal distress throughout any intervention

Direct questioningObservation

6. Demonstrates a thorough knowledge of health promotion issues for the client group and is able to access these. Educating in an effective manner to promote present and future well being.

Direct questioningObservation

7. Offers appropriate health advice for discharge with clear guidance of when to seek further medical help alongside information advice leaflets.

Direct questioningObservation

8. Demonstrates an up to date awareness of current research and how it relates on patient care

Direct questioning

PASS REFER

Candidates Comments/ signature Assessors Comments/ signature

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SUPERVISED PRACTICE FOR VOMITING AND DIARRHOEA PATHWAY

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No. Date Signature of Assessor

1

2

3

MONITORING COMPLIANCEThe regimen for monitoring compliance with the guideline is as described in the monitoring table in Appendix 1.

REFERENCES National Collaborating Centre for Acute Care on Behalf of the National Institute for health and Clinical Excellence (2009) Diarrhoea and vomiting for children caused by gastroenteritis: Diagnosis, assessment and management of children younger than 5 yrs. http://www.nice.org.uk/guidance/cg84/evidence/cg84-diarrhoea-and-vomiting-in- children-under-5-full-guideline2 ( accessed 17th June 2015)

National Collaborating Centre for Acute Care on Behalf of the National Institute for health and Clinical Excellence (2009) Diarrhoea and vomiting f children under 5: Parent/carer advice sheet to support consultation. http://www.nice.org.uk/guidance/cg84/resources (accessed 17th June 2015)

Hartling L, Bellemare S, Wiebe N, Russell K, Klassen TP, Craig W (2006) Oral versus intravenous rehydration for treating dehydration due to gastroenteritis in children. Cochrane Database of Systematic Reviews. Issue 3, CD004390.[Medline]

Armon K, Stephenson T, Gabriel V et al (2001) Determining the common medical presenting problems to an accident and emergency department. Archives of Disease in Childhood. 84, 5, 390-392.[CrossRef] [Medline]

EQUALITY STATEMENT The Royal Free London NHS Foundation Trust is committed to creating a positive

culture of respect for all individuals, including job applicants, employees, patients,

their families and carers as well as community partners. The intention is, as required

by the Equality Act 2010, to identify, remove or minimise discriminatory practice in

the nine named protected characteristics of age, disability (including HIV status),

gender reassignment, marriage and civil partnership, pregnancy and maternity, race,

religion or belief, sex or sexual orientation. It is also intended to use the Human

Rights Act 1998 to treat fairly and value equality of opportunity regardless of socio-

economic status, domestic circumstances, employment status, political affiliation or

trade union membership, and to promote positive practice and value the diversity of

all individuals and communities.

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APPENDIX 1: MONITORING TOOL Element to be monitored Lead Tool Frequency Reporting

arrangementsActing on recommendations and Lead(s)

Change in practice and lessons to be shared

Number of patients Discharged home on pathway

Rinal Desai

Audit 3 months and then every 6 months

Routine data capture

Samantha Milton

Number of patients re presenting

Rinal Desai

Audit 3 months and then every 6 months

Routine data capture

Rinal Desai

Time spent in Emergency Department

Rinal Desai

Audit 3 months and then every 6 months

Routine data capture

Rinal Desai

Patient feed Back Rinal Desai

Feedback Form

3 months and then every 6 months

Routine data capture

Samantha Milton

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