This week we have visited 4 Emergency departments and children’s assessment units across the East of England. The weather has followed us and unbeknown to many at the time it was really quite bad in Norfolk on Tuesday and lengthened our day considerably. We later learned that many nursing and portering staff slept at the hospital to ensure they could work the following day. This is a true reflection of what is great in our NHS. The weather reports caught up afterwards and hung over us all week. Despite our concern about a repeat performance in Peterborough on Friday when it started to snow we managed to complete our visits.
We received a warm welcome everywhere we went. It has been a re-visiting of old friends and showed the value in taking time to work collaboratively, establish relationships and build trust. We used an appreciative enquiry approach last year but all our expectations have shifted slightly this year. Our stance is still supportive but in more than one trust it was recognised how important peer review is and any recommendations from an external visit are essential to move forward the agenda. We were asked for clear recommendations.
There have been lots of examples of professionals working collaboratively and passionately demonstrating real progress. For example: The active recruitment of children’s trained nursing staff in a designated Paediatric Emergency Department. The appointment of a Paediatric ED Consultant. Collaboration between paediatricians and the lead GP CCG lead for children. Increased consultant delivered care in periods of peak activity. Even the development of Paediatric Nurse Practitioners. I will focus on the good practise another week but this week there are a few things I have been reflecting on.
Children aged 0-16 account for ~25% of ED attendances. In the trusts we visited this was 10,000-25,000 children and Young People per year. Three out of the four trusts had >16,000 attendances which means according to the intercollegiate standards for Children and Young People in Emergency Care settings they should have a paediatric emergency department and at least one child trained nurse per shift. Only one trust had a Paediatric Emergency department. One had one when we visited last year but it had been taken over by the Adult Ambulatory unit. In the one trust that did have a paediatric emergency department it was a fantastic well thought through use of space and a truly child and young person friendly environment with good visibility of the waiting area. In the other trusts generally the waiting areas and designated space for children to be seen was inadequate and mixed amongst the adult ED department. ED departments are scary places for children and Young people. Adolescents are often the worst served, they don’t want to sit in a room with small children and babies but are more aware of what is going on around them and find it frightening.
If Children and Young People account for 25% of ED attendances why do children’s trained nursing staff not account for 25% of the staff? We saw very small numbers of children’s trained nurses. In two 2 trusts we were told that there were 3 but when we drilled down 1 had been appointed only that week, 1 was on maternity leave and the 1 actually working was part time. (So just to spell it out 20hrs per week and by the way even in those 20hrs they cannot just see the children but have to turn their hand to looking after adult patients.) Despite this only 1 trust was actively recruiting children’s trained staff. Most looked slightly incredulous and were more concerned about “bums on seats.” I have great respect for all staff working in an ED environment and recognise they have a diverse and challenging role. ED nursing staff numbers and ED consultant numbers nationally are very low and recruitment challenging. For many years they have just got on with it and have accrued a great deal of experience. I understand that children have always been part of the mix but” If we always do what we have always done, we always get, what we always got.” Sadly this isn’t good enough for our children. “Improving child health services in the UK: insights from Europe and their implications for the NHS reforms.” http://www.bmj.com/content/342/bmj.d1277
As we have visited ED departments nationally we have observed first hand in those hospitals where they have managed to get the numbers of children’s trained nursing staff up to a minimum number to allow them to see all the children coming through the department these staff are valued and they do have enough work to do. When numbers are minimal in reality most of the time there is no one with a child qualification and so the ED nurses have to do it themselves and the benefits of having a children’s trained nurse not appreciated.
The gold standard model is to have a co-located ED and children’s assessment unit to allow staff to work across and share skills and learn from each other. This is work in progress but very much on the agenda for the trusts we have visited. I know over the next few weeks we will see this model in action.
Another thing we have seen this week is a hospital recovering from the bruising experience of having the CQC and Monitor reviewing them and overseeing external inspections following the death of a child in their ED department. Although not a common occurrence some children are more sick than realised and all trusts will experience this regretful occurrence at some time where the death was potentially preventable. The Confidential Enquiry into Maternal and Child Death (CEMACH) suggested up to 43% of child deaths had a possible modifiable outcome. (http://www.injuryobservatory.net/why_children_die.html)
The death of a child has a devastating effect on the staff involved. Just like the weather this week it can pass by under reported in one place and as top headlines in another. We heard about deaths in other trusts that were similar. It can be tempting to think a trust that has undergone an incident like this is bad or the staff not good, probably to reassure ourselves that it can’t happen to us. This is the trust that has a paediatric ED department and is actively recruiting children’s trained staff. It has a paediatrician who does sessions in ED and an ED consultant with an interest in children. It has increased the number of consultants and middle grade staff to cover periods of peak activity. Some of this was happening before the incident, some after.
To end on a positive there is always another way of doing things and sometimes we have to change. I don’t know all of the answers but I do know we must learn from each other especially trusts that have had these experiences. We must constantly review ourselves against standards and work through the priorities raised from these. We must talk about the challenges and find a way forward together.
Best Wishes Mel