Strategic Development of Paediatric Services

STRATEGIC DEVELOPMENT OF PAEDIATRIC SERVICES

WORKING ACTION PLAN (first version written May 2005)

Guidance / Current Position / 2005-2008 / New Hospital – 2010 / Lead Manager/Director
Getting the right start: National Service Framework for Children
Standard for Hospital Services, April 2003 / See attached OBC model of care and paediatric operating principles.
Children and their families need timely, relevant and effective personal and material support to help them cope with illness or disability. In addition to the generic support provided by all members of the multidisciplinary team, this includes:

Specialised support, such as that provided by mental health professional or social worker for those emotional and psychological difficulties

Support staff in place eg social worker. There are currently 3 sessions of child/adolescent psychiatry.
Full time social worker dedicated to paediatrics.
Currently exploring ad hoc psychology cover for identified patients.

Expansion of team. Employment of a full time child/adolescent psychiatrist -Business Case April 2006
Resubmit business case for 0.5wte psychologist – April 2006 which was agreed, recruitment process is underway with the Tavistock
Review of social work and psychology services Sept ‘06
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Dedicated paediatric team to include a child mental health team
Include psychologist in new hospital
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Shane McCabe

Spiritual support, provided by religious leaders or the chaplaincy service.

Available as needed. Chaplain in post who contacts other faiths as required.

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Support provided by peers: among children and young people and between families with similar problems.

Information around support groups available.

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Continue.

Help with transport and travel to tertiary or other referral centres, for example, through hospital transport schemes.

Provide hospital transport if required.

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Riana Horn, OPD Manager

Children visiting or staying in hospital have a basic need for play and recreating that should be met routinely in all hospital departments providing a service to children /

Play specialist available who visits HDU.
The Trust education service now has a link with a local school, Whitmore who have been awarded ‘science’ status within Harrow. We will facilitate students to come to the RNOH and visit key departments to learn about professions and roles in the NHS where science is required. This will also include some technical type job roles.
Following a review of Harrow tuition service last year, the School Development Service (part of Harrow Local Borough), has established principal advisers for age bands and for implementing the ‘inclusion’ policy. We will have links to them.
We are involved in the healthy schools programme.
Gail Burgess is planning to hold training sessions on basic non verbal communication methods such as makaton.
The educational service here are working closely with speech and language therapy to develop patient communication passports. These will be in place in the patient’s notes and set out (possibly with pictures too), the ways of communicating with the patient, preferences for meals, likes, dislikes etc.

Increase service provided by the play specialists, including expanding the team subject to business case – April 2006 Approved and posts x 2 (in addition to one post) out for recruitment.

Dedicated team of play specialists working throughout Trust, in all areas where there are children.

Shane McCabe & Siobhan Lalor-McTague

Staff, facilities and equipment are required to meet the ongoing educational needs of children and young people staying in hospital, with reference to the Department for Education and Skills guidelines on the education of children in hospital. /

Education service provided with links to Harrow LEA.

Further develop the education service - e.g. ‘makaton’ signing for CP children, communication booklet, exchange science classes with HarrowSchool, ongoing

Further develop the education service

Shane McCabe

At every location within the hospital where care is provided to children there must be staff trained in paediatric life support. Basic life support is generally sufficient in most areas of the hospital, to Advanced Paediatric Life Support (APLS) or Paediatric Advance Life Support (PALS). In these settings, ideally, there should be at least one person trained in APLS or PALS, or equivalent on a shift at any time. /

Training available on site for basic paediatric life support, staff.

Nurses undertake EPLS training, and doctors APLS training.

Current review nurses are EPL instructors.

High level of paediatric training.

Audit required

All staff caring for children to have received paediatric basic life support. Availability of an advanced paediatric trained member of staff to be on site at all times and member of the crash team – October 2006

All staff trained that have contact with children.
At least one staff member on duty in each area caring for children should have had advanced paediatric life support training

Siobhan Lalor-McTague and the Children’s Services Strategy Group

Safe recruitment practices for all staff, including agency staff, students and volunteers, working with children, including a criminal record review on employment (see Clothier Report (42). /

Safe guarding officers in post.
Paediatric staff all police/CRB checked.

All staff coming into contact with children in what ever form should be CRB checked. - actioned

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Mark Vaughn, Director of HR

Protocols should be in place across the hospital, particularly in surgical services, as well as on children’s wards, and should cover; resuscitation; pain management and sedation; fluid management; antibiotic regimes; and management of the conditions with which children most commonly present to hospital. /

Trust policies in place e.g the paediatric pain assessment tool was commenced in February 2006 and is used for all patients etc.

Introduce more specialised service e.g liaison mental health team – April 2007
Provide guidelines as hard copy and on shared network drive accessible throughout the hospital - Ongoing

Full schedule of paediatric policies, protocols and guidelines.

Siobhan Lalor-McTague and Children’s Services Strategy Group

Multidisciplinary child specific clinical audit should be undertaken in all specialities to which children are treated. /

Trust wide audits taking place e.g. record keeping and named nurse particularly for children at risk, medical staff audit of knowledge, experience in child protection etc.

Develop paediatric multi disciplinary audit programme. Undertake audits with other specialist clinical teams e.g spinal – April 2006

Continue audit programme.

Dr Nan Mitchell, Medical Director

As part of the overall trust clinical governance framework, arrangements should be in place to secure the safe and effective use of equipment in children throughout the hospital. /

Training available for all equipment.

All new equipment approved by purchasing group - actioned

All equipment standardised and training received.

Anthony Palmer, Director of Nursing and Clinical Governance

There is still evidence that pain is inadequately dealt with for children in hospital, requiring better prevention, assessment and treatment. /

Three CNS for Pain in post.
Pain assessment tool in place.

Develop paediatric pain protocol & tool. – February 2006 (completed and held at the end of each pts bed). Monitoring and audit of pain assessment tool – September 2006.
Develop a MDT approach to pain management – February 2006 completed.

Efficient use of protocol.

Alicia Thomas and Siobhan Lalor-McTague

Where procedures are planned, and pain can be predicted, the opportunity should be taken to prepare children through play and education, and to plan pain relief for use during the procedure. The use of psychological therapies, including distraction, coping skills and cognitive behavioural approaches, provides some benefit. . /

Verbal and written information given to patient with post op pain management covered.
Play specialist in post.

Update and develop information giving including information regarding Clinical Child Psychologist – April 2006 (awaiting appointment of Child psychologist)
Expand play specialist service – April 2006 Business case was successful and posts are out to advert and will cover the whole hospital (including out-patient areas)

Continue developing evidence based practice.
To have a fully established play specialist team

Shane McCabe

Children who have had surgery and have to stay in hospital overnight need nursing, anaesthetic and medical aftercare provided by appropriately trained staff. These are most likely to be found on a site with in patient general paediatrics. For single specialty hospitals, in the short term, special arrangements will be needed for the provision of paediatric cover. New split site arrangements should be avoided. Where these already exist, and where feasible, they should be phased out in time. /

24 hour anaesthetic cover available. Good links locally and sector wide 24 hour paediatric consultant available.

Recruitment to and expand Achieved May 2006 = 52% of ward nurses are RSCN (13 out of 24), one HDU nurse is currently doing the RSCN training and will complete in December 2006. specialist paediatric staff. 24 hour onsite cover for paediatrics - April 2006
Provision of a 24/7 anaesthetic outreach service with at least one team member with paediatric training – April 2008
Ensure all on call anaesthetists have APLS Qualification – December 2006
Provision of 9 a.m. – 5 p.m. middle grade paediatric cover 7 days per week – Business Case April 2006

50% RSCN achieved July 2006.
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Shane McCabe and the Children’s Services Strategy Group

Day case surgery can be carried out in a safe standard on a site where there is no paediatric service, but only if staff are able to deliver paediatric life support, and if a neighbouring children’s service takes formal responsibility for the children being managed there. /

Day cases cared for within paediatric unit.
Standard met.

Continue to provide day care surgery on the paediatric unit - Ongoing

Paediatric day care established.

Dedicated operating lists for children are the ideal, but it many specialities this is not practical or feasible. In these circumstances, children should be put to the start of the list with appropriately trained staff in the reception, anaesthetic room, theatre and recovery areas. Policies and protocols specific to the needs of children are required on issues such as preoperative starving. /

Children at start of list, pre op starving policy available for paediatrics.
Lack of suitably qualified children’s nurses in theatres, recovery and anaesthetics and ITU.

Review scheduling and look at moving to paediatric only lists – December 2006
Appoint additional child branch nurses across children’s pathway to required standard - (up to 13 out of 24 nurses) Ongoing
Second nurses for training (including one nurse from ITU/HDU)- Commenced and due to return to RNOH HDU Dec ‘06

Continue to move to dedicated paediatric operating lists (increase the number of paediatric lists per week from 3 up to 6).
Continue to strengthen nursing across patient journey.

Shane McCabe and Children’s Services Strategy Group

Ideally, children should only need to visit tertiary centre for complex assessments and investigations or specialised treatment. Otherwise tertiary care can be delivered locally through outreach services operating within a clinical network, provided that the network itself is adequately commissioned, funded and staffed, and that there are clear system for information sharing, clinical governance, accountability and staff development. /

Caring for complex and special conditions that cannot be performed elsewhere using all support networks in hospital.
Current relationships with
GOSH
NWL
St Mary’s
Good relationships exist with other relevant hospitals.

Continuing to ensure safe systems in place expanding paediatric team - Ongoing
Review externally how network could enhance paediatric services - Ongoing

Facility for dedicated paediatric service.

Diagnoses and manages unusual problems, delivers unusual or complex treatments and where these are new or experimental, does so in the context of a clinical trial.

Providing unique service for paediatric group.

Developing new treatments e.g. Ibandronate sub-cutaneous drug therapy for patients with metabolic bone disease, further develop surgical intervention using osigraft bone regenerator for patients with non-union conditions, continue the research and improved non-surgical limb lengthening for paediatric patients, using data from the motion analysis assessment of patients to exactly prescribe the surgical correction required to elicit improved motion/gait etc. - Ongoing

Expanded paediatric service will enable further new and experimental work.

Has sufficient staff to provide safe, round the clock cover for acutely ill children, and at the same time undertake a range of outreach services, including peripheral clinical, nursing support services, telephone support lines, teaching programmes and exchanges for staff.

Specialist nurses available, multi professional team in post. Not 24hours.

Develop service and expand paediatric and other staff dedicated to paediatric patients - Ongoing
Ensure 24 hour cover April 2006
Outreach services to be further developed – April 2006 Being discussed Paed. Matron and HDU Sister to devise an outreach proposal.

Dedicated paediatric service with 24 hour onsite cover.
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Shane McCabe and the Children’s Services Strategy Group

Admit as inpatients only those children for whom local hospital admission is not a safe or acceptable option, for instance, because surgical intervention might be needed urgently, or complex treatments, investigations or specialised nursing care are required.

Admission criteria assures this currently.
Specialist nature of services at RNOH ensures that only relevant children treated.

Promotion of work being done within paediatrics –update the Trust website – May 2006-07-06
Produce an updated ward leaflet and conduct an audit of patients to ascertain the usefulness or otherwise of the leaflet. January 2007
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Developing paediatric team and service delivered.
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Has reliable arrangements for paediatric intensive care retrieval and other emergency transfers.

Use of CATS retrieval.

Extend skills continue to use CATS - Ongoing

Continue to use CATS

Plans transition into adult care for long term conditions.

Spinal team developing their transition.
Many clinicians currently providing orthopaedic care to children into later life.

Ensure other specialities are planning the transition for their patients with long term conditions - Ongoing

All children requiring long term care to have planning for transition into adult care

It will be necessary to ensure sufficient capacity for high dependency care. This will prevent unnecessary referrals to PICUs for children who do not require intensive care. /

Children cared for in HDU.

Improve training for staff provide high dependency nursing on paediatric ward area when required - HDU/ITUOutreach Started November 2005. Outreach provided bedside training for the nursing staff and exchange or shifts by staff in both areas. Ventilated patients now being accepted and cared for on the Paediatric wards.

Dedicated paediatric HDU.

Siobhan Lalor-McTague and Redevelopment Team

Children should not be cared for on adult wards, but on wards that are appropriate for their age and stage of development. In particular, the needs of adolescents require careful consideration. In general, adolescents prefer to be located alongside other people of their age. /

Paediatric unit divided into two age appropriate areas, under 12 and over 12 years of age.
Paediatrics on one PPU ward only in single rooms.
Paediatrics in ITU nursed alongside adults unless in a single room.

Continue to ensure paediatric service delivers age appropriate care - Ongoing
Children who are admitted to PPU to have consistent, equitable care and access to the full MDT range of staff as those admitted to the main paediatric/adolescent areas – currently under review daily by the Paediatric Modern Matron.
Create a child friendly environment in ITU/HDU and recovery - Feasibility currently being explored
Patients are being admitted to the NHS wards gradually in conjunction with the admitting Consultant – June 2006. Feedback audit will be conducted.

Purpose built paediatric and adolescent wards.
Purpose built area ITU/HDU for children

Redevelopment Team
Shane McCabe

Named individual with responsibility for planning and delivering services for children and young people. /

Multi professional planning approach with paediatric consultant involvement.
Exec lead for Paediatrics.

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Identify a Non-Executive Director to provide leadership at Trust Board – December 2005 completed, Stecia Ladie attends the RNOH Children’s Strategic Group meetings.

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Each Patient’s Forum will be required to develop strategies to include young people. /

Initial project looking at waiting times in OPD, will include paediatric patients and their families.

Ensure Patient Forum projects capture children and young peoples’ views - forum has visited the paediatric areas_ January 2006 (completed)
Use feedback to make appropriate changes – April 2006
Request the patient forum to conduct a re-audit in January 2007 of patient and parent views on the service.
Utilise audit feedback to refine services.
Identify member of Patient Forum to take a lead on Children’s Services – January 2006 (completed)

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Riana Horn, Outpatients Manager

Consider the ‘whole child’ not simply the illness being treated. /

Multi professional approach with regular meetings (including staff from all Trust depts. Where children are seen e.g. out-patients, plaster room, HDU, theatres, OT, Physio etc.

Expand the paediatric team and ensure that multidisciplinary meeting continue - Ongoing
Whole tem to be involved in the MDT meetings - Actioned

Full dedicated paediatric multi professional team looking at all the needs of the child together