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Past, Present and Future

• Contributions from
• Sinclair Molloy, Health Care Manager Emergency /
  Urgent Care
• Dr Bridget Oates, Consultant Paediatrician
• Jean Davies, Senior Paediatric Nurse
• Irene Campbell, Project Manager PFPI Your Health

HEAT 10 Networking Event 12th November 2010
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Analysis
Social Marketing
Acute Paediatric Services
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Observations

• NHS Ayrshire and Arran has amongst the highest
  paediatric emergency inpatient admission rate in
  Scotland and all paediatric admissions are
  triaged in AE.
• Attendance is on an upward trend (up 3.1 per yr)
• Even more so in the under 5s (up almost 7 per
  yr)
• Eight of the last ten months are all time highs
  for U5s
• Can changes in population explain this?
• Attendance seems to follow the general pattern
• Highest in Sunday/Monday and in the Spring
• There are moves from Mon to Wed/Thus in FY1011
• U5 attendance moving to later in the evening
  (6pm-8pm)
• Are these changes real? Will need to wait and
  see.
• A huge proportion of Paediatrics are self
  referrals
• GP Referral has almost halved proportionally for
  U5s
• ..but GP referral has increased for A5-16s

Based on AE Data only
Bryan Samuel, Senior Information Analyst
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Gaps in the analysis

• Very little diagnosis data is available.
• Its difficult to identify social groups.
• No information on family relationships.
• No information on family behaviour.
• There is no way of identifying shifts from other
  parts of the service.
• Paediatric frequent attendance has not been
  investigated so far.
• Need to consider the relative population change
  in paediatric patients.
• Will need to wait for completion of FY1011 to be
  sure that any change in behaviour is real.
• Need to look at other data sources (Out of Hours,
  NHS24 etc).

Bryan Samuel, Senior Information Analyst
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Redirections from AE to ADOC

• Redirections are currently taking place from the
  Emergency Department at Ayr to NHS ADOC for
  children and young people presenting with
  suitable minor illness conditions.  
• This redirection process has been in
  place throughout 2010, with no reported
  challenges to date. The redirections to NHS ADOC
  on the Ayr site have the added patient
  benefit of a co located site.
• Redirections for children and young people
  from Crosshouse Emergency Department to NHS ADOC
  are in the early discussion phase at this time,
  attributed in part to the separate locations of
  the Emergency Department and NHS ADOC, Lister
  street. Progress around the criteria for suitable
  redirection is anticipated in early 2011.

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Caring for the children of Ayrshire

• Dr Bridget Oates, Consultant Paediatrician
• NHS Ayrshire Arran

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Huge changes in provision of paediatric services
in 2006
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Goals

• Further improve the already high standard of
  acute paediatric care given to the children of
  Ayrshire.
• Facilitate the rapid assessment and appropriate
  management of children presenting to the acute
  paediatric services.
• Concentrate a pool of paediatric medical and
  nursing expertise.
• Reduce unnecessary admission to the paediatric
  ward.
• See and process children for day case
  investigation or treatment.
• Create a workable interface between primary and
  secondary care allowing GPs rapid access to a
  senior paediatric opinion.
• Increase educational opportunities for both
  junior medical and nursing staff to learn about
  emergency assessment and the philosophy of
  ambulatory care.

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Old System

• 3 wards on 2 separate sites
• General ward in Ayr Hospital 18 beds
• Medical ward in Crosshouse 28 beds
• Surgical ward in Crosshouse 20 beds 6 day case
  beds
• Total of 72 beds
• Children came directly to the in patient ward
  from primary care.
• High admission rate was a trade off for safety

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Current Situation

• Inpatient ward in Crosshouse 23 beds (16
  cubicles) includes 4 adolescent beds
• Ambulatory unit (CAU) with 10 beds
• - 4 bed bay for emergency referrals
• - 4 bed bay for day cases
• - 2 cubicles
• Total 33 beds

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Expected Medical and Surgical Patients referred
to On Call Paediatric Team
GP Referrals or 48 hour open access
patients Chronic Patient with open access or
other referral
Present to Paediatric AE suite for Triage
Other Triage Category
Triage Category Red or Orange
Transfer to CAU
Resuscitation Area in AE and emergency call to
paediatric registrar
Stabilisation
Observe in SSAU for up to 6 hours or until ward
round if after 10 pm
Discharge Home
Admit to Paediatric inpatient ward
Transfer to ITU in Crosshouse
Transfer to ITU in Yorkhill
Note Those patients presenting in extremis or
coming by ambulance and deemed to be Stand by
patients will go directly to Paediatric
resuscitation bay in the main AE area.
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Children Self Presenting to AE
Present to Paediatric AE suite for Triage
Triage category Red or Orange
Other Triage Category
Resuscitation Area in main AE and emergency
call to appropriate medical staff
Discharge Home
Seen and assessed by AE medical and nursing staff
Stabilisation
Referred to and assessed by appropriate surgical
subspecialty
If child for inpatient management clerked in AE
Transfer to CAU for review
Discharge Home
Transfer to ITU in Crosshouse
Transfer to ITU in Yorkhill
Observe for up to 6 hours or until ward round
if after 10 pm
Admit to Paediatric inpatient ward
Note Those patients presenting in extremis or
coming by ambulance and deemed to be stand by
patients will go directly to the paediatric
resuscitation bay in the main AE area
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Present Service
Child Family Health Event

• Follow Up

Childs Journey
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Childrens Assessment Unit Benefits

• Improved Care
• Concentrated a pool of medical and nursing
  expertise.
• Facilitated rapid assessment and appropriate
  management of our children
• Reduced unnecessary admissions

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Relationship with ED

• Fluid interface between the CAU and ED.
• We are really one big department looking after
  children, not 2 separate ones!
• Single entry system.
• Commonality of guidelines with ED

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Hot Clinics

• Available to each Consultant on a daily basis
• Patients do not need to go through ED triage
  system
• Follow up then arranged as necessary like any
  other out patient

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Follow up and Open Access Folder

• 48 hour open access
• Out patient review on assessment unit.
• Out patient follow up in appropriate
  geographical area
• Open access folder specific patients with
  complex health needs

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Audit Data Collection

• 1st January 30th June 2007
• summer / winter divide
• Data collected from
• Record of referrals
• Case notes
• Typed discharge letters
• Data anonymised and stored on database (Microsoft
  Access 2003) prior to analysis at the end of the
  study

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• 2007 audit data
• 97.3 (n2040) resided within Ayrshire
• 57 children were from out with Ayrshire
• 30 from other parts of Scotland
• 27 from elsewhere
• 2287 children seen
• 88 children per week 2010 data
• Data complete for 2099 (91.8)
• Slight male preponderance (ratio 1.2 1)

Crosshouse Hospital
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28 under 1 year of age
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Time of Day

• 42 arrived during the normal working day
  shift
• 27 arrived during the evening
  shift
• 31 arrived during the night
  shift

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Referral Source
Primary care 49.5 ED 43.9
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Discharge Destination

• Admitted to Crosshouse 34
• Admitted other hospital 1
• Unknown 2
• 63 discharged home

Acute bronchospasm Viral illness Bronchiolitis LRT
I Gastroenteritis
compares favourably with 40-60 reported by
other UK Units1
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48 hour Open Access

• 69 children (5 of those discharged) returned to
  the Unit
• Comparable to other UK Units (0.442 73)
• Most common diagnoses gastroenteritis
• 20 children admitted as a result of a return visit

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Summary

• We have improved the acute hospital care for the
  children of Ayrshire.
• Access to acute paediatric services should not be
  restricted to those requiring hospital
  admission.
• Children are not being admitted to hospital
  unless absolutely necessary.

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Thank you and Questions?
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Targeted Social Marketing

• Irene Campbell, Project Manager PFPI, Your Health
• Project Manager for Public Education Campaign

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Focus Group 2009

• It is a nightmare at times trying to access an
  appointment. People are so peeved off and they
  are thinking if they phone up and need to give a
  whole spiel to someone or wait 3 weeks and I know
  people are not willing to go through this and
  take their children to AE.

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Public Education Campaign

• Targeted public education campaign
• 2 strand approach - whole population
• Targeted approach postcode analysis
• Targeting 17 35 year old males
• Targeting children
• Range of materials/approaches

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Message to children

• Poster design campaigns at local primary schools
• 4 locations
• Poster winners posters to be displayed locally

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How have we targeted 17 35 year old males?

• Campaign launch at Kilmarnock v Celtic match 19
  September (8645)
• Beer mats distributed via local licensing
  departments
• Publicity shot with Kilmarnock football team
• Radio campaign West FM Westsound

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How have we included children/young people?

• 6th Year Pupils win an i-tunes voucher
  competition (77 entries)
• Leaflet to be put in all school bags at targeted
  schools, secondary and primary
• Materials to all local colleges

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In addition

• Booklet in Red Book
• Target student unions
• Focus groups
• Mothers Toddlers groups

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Thank you
Any questions?