Facing the future: standards for children in EM settings

Today saw the launch of the new RCPCH ‘Facing the Future’ document – setting standards for paediatric emergency care in the UK. These are a set of standards that should apply to all Emergency Department where children are seen and assessed.

The goal is for all emergency care services to be able to audit themselves against these standards.

It’s a 90 page document and you can read the full version here.

Here is our summary of the key points:

1. An integrated urgent and emergency care system

1. The focus is on a whole system approach where all services work together in established clinical networks – including GP services, urgent care centres, acute paediatric services, schools, pharmacy, community services, and ambulance services. They should have shared care guidelines, and evaluation processes across the whole network.
2. Staff in urgent care centres should have appropriate paediatric competence.

2. Environment in emergency care settings

• Provide an appropriate waiting area including refreshments, breast-feeding facilities, and entertainment.
• Involve children and young people and their parents in service design.
• Have access to a play specialist.
• Encourage patient/parent feedback.
• Provide appropriate discharge information including written and verbal safety-netting.
• Use patient flow models when planning the use of the environment.

3. Workforce and training

• Every ED treating children should have a PEM consultant who delivers clinical time in the department.
• Every ED treating children should have two children’s nurses on a shift.
• Staff should have professional development training hours for learning events.
• A member of staff with APLS should be on duty and all staff should have BLS.
• PEM Consultants should have SPAs in their job plans.

4. Management of the sick or injured child

• Where children are being streamed away from ED this must be done by someone with paediatric competences
• All children should be visually assessed on arrival by a doctor or nurse and have a clinical assessment (for triage) within 15 minutes. There should be an escalation policy when the triage wait exceed this.
• all children should have a pain score and vital signs within 15 minutes.
• Children with abnormal vital signs should have their obs repeated within 60 minutes.
• Every ED should have an early warning system in place and an escalation policy for critically unwell children
• The appropriate range of drugs and equipment should be available.
• Children with moderate and severe pain should have analgesia dispensed within 20 minutes and a reassessment of their pain score within 60 minutes.
• Health promotion and prevention should be delivered and recorded in the notes.
• Discharge summaries should be sent to the relevant healthcare professionals within 24 hours.
• The ED should work with community services to prevent hospital admissions.

5. Safeguarding in emergency care settings

• All staff looking after children should have up-to-date safeguarding training.
• There should be a lead consultant and nurse for safeguarding.
• There should be departmental safeguarding guidelines.
• All staff should have access to 24 hour safeguarding advice from a paediatrician with expertise.
• All staff should have access to Child Protection Plan information, systems should be in place to identify frequent attenders, and staff should recognise the impact of a carer’s health on the dependent.
• The primary care team should be informed of each attendance and an approved information sharing system should be in place.
• There should be a policy for when a child leaves or absconds unexpectedly, and a review of the notes should be undertaken by a senior doctor or nurse for all children who leave before being seen.
• All children with potential safeguarding presentations should be reviewed by ST4+.

6. Mental health

• All children should have their emotional and mental health needs assessed.
• Risk and capacity should be documented for all patients with a mental health crisis.
• Have an appropriate space (including a safe room) for children/families in crisis.
• Have access to mental health records and crisis plans (can be via CAMHS) and an appropriate escalation pathway.
• Clinicians should be provided with training on assessing risk, capacity, consent, and parental responsibility.
• Have 24 hour access to a mental health practitioner.
• Have a policy for managing the acutely distressed young person.
• Have a suitable inpatient facility to look after patients requiring an inpatient mental health facility where there is a delay in accessing it.
• Have a clear pathway to identify a place of safety for those on a Section 136 order

7. Children with complex medical needs

• Have a triage system that considers the prioritising care for children with complex medical needs and provide training on early escalation.
• Have individual emergency care plans available and ensure any electronic alerts are used to show special instructions.
• Consider the child with complex needs when designing and planning for the department.
• Share information about attendances with the relevant professionals.

8. Major incidents involving children and young people

• Ensure that children are specifically considered in planning for a major incident response and involve paediatric staff in incident exercises.

9. Safe transfers

• Each region should have a Paediatric Critical Care transport team managed by the Paediatric Critical Care Operational Delivery Network.
• Have access to a regional PICU with a 24 hour helpline providing support and advice.
• Have local facilities and staff for time-critical transfers.
• Have ED staff trained in patient stabilisation and transfer.
• Provide information and practical help for families where children are transferred between hospitals.

10. Death of a child

• There should be a local policy for responding to the unexpected death of a child.
• Children who have died outside hospital should be taken to a hospital with paediatric facilities.
• All staff should have training on how to support families where there is an unexpected death.
• There should be co-operation with the Rapid Response team and the Child Death Overview panel.

11. Information system and data analysis

• All ED staff should have an information system providing episode related information and demographics.
• All health organisations providing emergency care should collaborate with national information centres.
• All EDs treating children should collect performance data to improve services.
• All EDs treating children should have discharge summaries compliant with PRSB standards.

12. Research for paediatric emergency care

• All EDs treating children should have a nominated lead for paediatric emergency research with PERUKI membership.