This example describes how we applied NICE guidance (NG143 for assessment and initial management of fever in under 5s, CG84 for diagnosis and management of diarrhoea and vomiting caused by gastroenteritis in under 5s and CG176 for the assessment and early management of head injury) to enable development of a whole system localised pathway redesign methodology.
This ensured confidence relating to managing any risks associated with changing practice in paediatric urgent and emergency care.
This example was highly commended in the 2015 NICE Shared Learning Awards.
This example was originally submitted to demonstrate implementation of NICE guideline CG160. The guideline has now been updated and replaced by NG143. The example has been reviewed and practice described remains consistent with the updated guideline.
Aims and objectives
The aim of the project was to develop a stepped approach towards a shift in clinical efficiency and effectiveness and an increased ability to provide clinically effective, cost efficient and safe healthcare.
- Breaking down of professional barriers and successful joint working.
- Development of a repeatable methodology for whole system pathway development.
- User involvement (parents, children and young people) in system redesign.
- Development, testing, review and implementation of whole system clinical pathways.
- Identification of metrics and process to measure the impact.
- Development of consistent urgent and emergency care signposting and clinical guidance for parents / carers and users of local services.
- Schools involvement in a national PHSE pilot aimed at increasing awareness about how to use urgent and emergency care services.
- Raised profile of children's services within urgent and emergency care.
- Identification of potential financial savings across the system related to more efficient use of local resources.
Reasons for implementing your project
At the time, Luton was an outlier region with a comparatively high rate of non elective admissions. A review of activity identified 6 common conditions which account for 85% of all children's emergency activity. Luton identified that reviewing these high volume conditions and developing a new community/acute working model would improve quality and value for patients.
The aim was to provide a seamless service across the local social and health economy to enhance quality of service delivery. Local parents reported inconsistent information about where they should go for advice and treatment. This appeared to be in line with the default position to attend the local emergency department reflected in the high number of attendances. Parents also described how their children had waited and been treated next to adults within the department which they did not feel was appropriate.
The original data used to commence the project related to the outlying position for non-elective paediatric admissions held by Luton within the East of England and nationally. The top ten HRGs for high volume non-elective admissions were subsequently reviewed programme objectives and metrics to measure improvements were identified. In order to achieve a baseline to demonstrate impact simple data sources were agreed:
- Paediatric emergency admissions L&D NHS FT per 1000 - NHS Comparators
- Paediatric non-elective attendances at L&D NHS FT A&E
- Paediatric emergency admissions at L&D NHS FT
- Top 10 HRG's for NHS Luton
- Emergency paediatric zero length of stay admissions at L&D NHS FT
The data was sourced from both NHS Comparators and local data derived from SUS.
Workshops attended by all relevant stakeholders were held to develop draft pathways and patient information leaflets. The pathways and information leaflets developed during the workshops were refined at monthly meetings. Prior to testing in GP practice over a 2 week period, expert opinions were sought. Over 40 service users and parents, families and carers at 15 Children's Centres were consulted about the pathways/leaflets. Their feedback directly influenced the final versions.
Increased quality, efficiency and improved safe working practice by localising national guidelines. Reduce variation in clinical practice across different access points of the urgent and emergency care system. Standardised clinical information regarding normal paediatric values for assessment for use across the whole system.
How did you implement the project
A series of workshops were held with staff across the whole system to develop draft pathways and patient information leaflets. Attendees included GPs, community nurses, A&E staff, paediatricians (acute/community), paediatric nurses, ambulance service and commissioners.
The focus of the workshops were to map the current journey of a child with specific common conditions, reviewing the vision for the future pathway, investigating then locally applying the evidence base. Based on NICE guidance and a 'traffic light' RAG format, the pathways direct practitioners to assess for signs of deterioration using the RAG system then follow the treatment pathway depending on findings.
Luton has developed 7 urgent care pathways, Fever, Bronchiolitis, Gastroenteritis, Head Injury, Asthma, Seizure and Abdominal Pain and where NICE guidance was available the team agreed it made the task easier providing assurance to the whole process.
It was agreed that applying the NICE guidance to the pathways would enable our whole system to develop a localised pathway redesign methodology whilst feeling confident about managing any risks associated with changing practice in paediatric urgent and emergency care.
A number of challenges were addressed throughout the project. Initially it had been difficult to agree age bandings and comparative data sources to establish a reliable baseline. It was recognised that different parts of the system coded information differently and there was no one stream of information shared across all access points that could be easily measured making access to data problematic.
To overcome these difficulties minimal data modelling support was commissioned in the early stages of the project which proved invaluable in developing a model that evidenced effectiveness. Initially there was no simple way to collate activity as areas were not routinely collecting such data therefore as an interim solution manual systems were set up.
The project team managed the work within existing resource; nevertheless it quickly became clear that the project required dedicated lead clinical time. Two nurses from acute and community were seconded 1 day per week to take the lead on the clinical development of the pathways. It is recognised that without the commissioner lead, the dedicated clinical support and the commitment of the whole system clinical project team the project would not have been sustainable or successful.
This innovative work demonstrates the impact of integrated multi-organisational working aligned to early intervention therefore enhancing quality and realising value by default. Expectation of service delivery is to ensure children and young people are treated in the right place at the right time. Reducing hospital attendance for low level illness which can be effectively treated either at home or by primary care. Whilst, ensuring children that need urgent care receive it appropriately and there are fewer delayed presentations.
Implementing whole system pathways based on NICE guidance has improved safe working, improved confidence in decision making increasing staff skills and capabilities by:
Standardising clinical information regarding normal paediatric values for assessment to reduce variation across parts of the system.
Increasing the number of necessary and decreasing the number of unnecessary tests, therefore ensuring patients move through the system quicker improving:
- the quality of the experience increasing patient and staff satisfaction
- efficiency/better value for money.
Change which patients are referred to the Paediatric Assessment Unit (PAU) from both GPs and the Paediatric Emergency Department and increase the number of safe discharges home.
Key to the success of this project has been due to the development of the governance framework including project leadership and performance reporting. The project group are committed to championing the project's cause, maintaining focus on outcomes by prioritising competing responsibilities and completing work within the resource.
Evidencing the impact of the urgent care pathways has been challenging as there are variables that could impact on performance. However we have strived to triangulate information to ensure a more robust picture. Project tools include audit of referrals to PAU/patient notes, analysis of bespoke reports that evidence averted admissions and length of stay for those patients admitted.
Our initial focus to evidence the impact of the pathways had been on reducing inappropriate attendance on PAU <2hrs activity trend continues to fluctuate due to expected seasonal variation but stays below the highest peak seen in March 2012. What we hadn't appreciated was the impact on admission LoS. We have evidence of a notable decrease in activity for short and long stay admissions where performance is under focus as a result of implementing the urgent care pathways.
Key learning points