Acute Care Pathways

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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ProfessionalsHealth Visitors

CommunityChildren’s Nurses

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Urgent Care CentreAmbulance

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MIMI Unit*Walk in Centre

Children’s Assessment

Unit

Ward

Children’s Critical

Care

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Home CAMHS**

Dedicated children’s environment and play facilitiesChildren and young people’s trained workforce

Child protection systemsSystem wide information

CYP and Family Involvement

* Minor illness, Minor Injury Unit ** Child and Adolescent Mental Health Service

Self Referral

Referral from the community

Open AccessSelf referral

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

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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]


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]


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]


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]


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?

http://dx.doi.org/10.1007/s40268-014-0052-x

• 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).


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.


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


http://www.nice.org.uk/guidance/cg84/chapter/key-priorities-for-implementation

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.


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

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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

Acute Care Pathways

Documents

Transcript of Acute Care Pathways