Paediatrics Pathways at EDGH – Improving Urgent Care – 1 December 2023

Health Overview and Scrutiny Committee Update, requested for 14 December 2023

Background

Paediatric service provision at East Sussex Healthcare NHS Trust is split across our two acute hospitals. All in-patient care, emergency and higher acuity need is met at Conquest Hospital, along with outpatient services, planned investigations and inpatient surgical needs. Eastbourne District General Hospital (DGH) does not have an in-patient ward but does provide urgent care, outpatients, planned investigations and day surgical services. Both sites were rated ‘Good’ by the CQC in 2020, although staffing challenges were noted.

At both sites the majority of urgent care for children is actually provided by each Emergency Department (ED). The Eastbourne site had 13,471 attendances in 2022/23, of which 91% did not require specialist paediatric input.

On both sites a Short Stay Paediatric Assessment Unit (SSPAU) was set up some years ago, to support urgent activity. Hospitals similar to Eastbourne DGH without in-patient wards usually co-locate assessment units / areas for urgent paediatrics within their EDs to improve access, speed of service and allow closer interaction and support between the paediatric and ED teams.

We have not historically been able to do that at Eastbourne DGH and currently the assessment unit is a significant distance away from the ED at the other end of the hospital. It is also challenging to staff the unit at Eastbourne and as a result it has been closed on weekends since July 2022 and closes earlier in the day than is ideal to support ED.  The assessment unit at Eastbourne sees roughly 3 to 4 children on average per day for urgent assessment, and on average about 1 child per day requires transfer from Eastbourne DGH to Conquest to meet their care needs. All ambulances conveying children go to Conquest.

The review of the current service arrangements was undertaken following the consideration of best practice as part of the new hospital clinical pathways programme of work, where the aim is to develop an emergency floor with service co-located to reduce unnecessary patient moves, bringing the clinicians to the patient, improve patient experience and reduce time spent in hospital settings where this is not required.

Service Development

Urgent Care

A review of the future arrangements of the SSPAU at Eastbourne DGH found that there was an opportunity to move the urgent elements of the SSPAU service, including the ability to observe and assess children, to a dedicated paediatric area adjacent to our Emergency Department. The aim is to:

· Improve the speed and access for children needing urgent care at Eastbourne DGH

· Improve the hours that the service can be offered to support ED across 7 days

· Enable a more effective and sustainable staffing model which includes the development of Advanced Paediatric Nurse Practitioners (this is the long term plan for ED adjacent services on both sites)

This means that urgent paediatric cases will be managed in a child-friendly area in ED, including any that need longer observation, and will be supported by Advanced Paediatric Nurse Practitioners (or paediatric registrars/middle grade doctors) who work adjacent to ED. They will not have to be transferred to a separate location. Initially the plan will match the 5 day provision currently offered by the Eastbourne SSPAU, but will increase to 7 days and longer hours. A Paediatric Consultant will be available to provide advice, support or attend as required.

Management of self-presenters that become critically unwell would continue to follow the existing “management of critically ill children presenting unexpectedly at Eastbourne DGH pathway”; as per this pathway ambulances convey critically ill children to Conquest Hospital. 

This approach to ED adjacent urgent care is also part of the long term plan for Conquest Hospital and being designed into plans for both sites under the New Hospital Programme.

Clinical and operational teams have been involved in reviewing pathways and the most appropriate place at Eastbourne DGH for patients to be seen.

Day Surgery

Children requiring day case surgery, are currently recovered within the theatres area and discharged home. That will continue until the new elective hub is completed where they will be treated and discharged from the unit, which is best practice for day surgery and has been designed accordingly.

Planned Care

The majority of children are seen within the out-patients area and that will continue.  The plan is to retain all the planned work we currently use the SSPAU to deliver at Eastbourne DGH, but in an outpatient type setting (or even at home) rather than alongside the urgent cases.  

In summary whilst patients will be seen in different locations more appropriate to their needs, there are no planned changes to the pathways which impact on patients moving to another site and this is summarised below.  The team are also considering where possible that some appointments may be able to be done remotely so that travel to hospital settings is reduced.  The skill-mix required to support each clinical setting has been reviewed and as such will affect some staff, for which there has been a formal HR consultation process undertaken.

The planned improvements are due to start in January.

Pathway at EDGH	Current Model	New Model	Extra transfers to CQ?
Critically unwell children presenting to ED	Immediate resuscitation/stabilisation by EDGH ED/Anaesthetics. Paediatric consultant on site in one hour. Transfers to Conquest as per current protocols.	No change	0
Acute Paediatric presentations to ED	Initially seen in EDGH ED. If paediatric specialist input is required children are streamed & moved to EDGH SSPAU (if it is open). Transfers to Conquest as per current protocols.	Will be seen in EDGH ED by paediatric specialist, and can be observed in EDGH ED if required. Transfers to Conquest as per current protocols.	0
Urgent GP referrals	Children likely to need admission are directed to Conquest. Children unlikely to need admission are seen on EDGH SSPAU.	Children likely to need admission are directed to Conquest. Children unlikely to need admission seen by paediatric specialist in EDGH ED.	0
Ambulatory care	Seen on EDGH SSPAU	Managed by the community nursing team with support from paediatric consultant.  In the future through virtual ward	0
Elective surgical pathways for children	In-reaching to DAU/Jubilee for Paediatric Nursing support.	No change. Paediatrician support from consultant in clinic.  Will ensure Paediatrician cover on days where surgery is running at EDGH.	0
Elective medical investigations	Carried out on EDGH SSPAU.	Nurse-led model to be carried out on Scott Unit/OPD with Paediatrician available in OPD.	0

Joe Chadwick-Bell

Chief Executive

Dr Matthew Clark

Chief Women’s and Children’s Services

Consultant Paediatrician

29 November 2023