Facing the future: standards for children in emergency care 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

  • 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.
  • 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 and 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.
Cite this article as:
Davis, T. Facing the future: standards for children in emergency care settings, Don't Forget the Bubbles, 2018. Available at:
http://doi.org/10.31440/DFTB.16004

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Can Point-of-Care CRP testing identify children with serious infection?

As paediatric emergency clinicians, a large part of our job is identifying the child with a serious infection. The utility of blood tests in helping with diagnosis in this group of children is debatable. Could point-of-care CRP testing help identify children with serious infection?

Verkabel JY, Lemiengre MB, De Burghgraeve T, et al. Point-of-care C reactive protein to identify serious infection in acutely ill children presenting to hospital: prospective cohort study. Arch Dis Child, 2018, 103:420-426.

Background

In the UK, there has been a 40% rise in children presenting to Emergency Departments in the last decade. 14% of children presenting to ED have a febrile illness. It is our job to decide which children can be safely discharged. CRP has been previously considered to have some potential diagnostic value in ruling out serious infection.

This study aimed to develop a tool which includes PoC CRP testing to help identify children with serious infection.

Objective

The objectives of the study were clearly laid out – to use point-of-care (PoC) C reactive protein (CRP) testing to improve the assessment of children presenting to hospital. However, the actual objective was including CRP as part of an algorithm including clinical features and vital signs. This should be made clearer in the title.


Population, patient and problem

Eligible patients were between 1 month and 16 years of age, presenting to six EDs and six urgent assessment units with an acute illness in Belgium over a one year period.

Patients were excluded if the acute illness was due to trauma, mental health problems, a chronic condition, a neurological condition, or if they were referred by their GP.

From an initial 8962 patients assessed for eligibility, after exclusions there were 5517 illness episodes (2895 presenting to an urgent care clinic, and 2622 presenting to the emergency department)

Design

The study design was suitable for the objective and looked at a group of patients common to our practice. It seems like an appropriate patient group to use, although I am not clear of the reason behind excluding patients who were referred by the GP. Perhaps this puts the child in a category of higher suspicion for serious infection (SI)? A sample size estimation was calculated. 

 

Intervention

Patients were assessed for 61 different clinical features – these features are broken down into a few main categories – demographics, history taking, observation, clinical examination, and diagnosis/management. Patients were also asked whether the current illness was different from previous illness; and were asked if the fever resolved with anti-pyretics. They then had a PoC CRP.

Measurements

These 61 measurements appear valid and include all the things you would ask parents when taking a history from an unwell child. Many are subjective (particularly the examination ones) and so will be clinician-dependent – for example ‘pale’ or ‘skin turgor‘. Additionally, I’m not clear about the significance of asking if the fever has resolved with anti-pyretics.

 

Outcomes

The primary outcome was hospital admission (>24 hours) for SI within five days of the initial presentation. SI was defined as: septicaemia, meningitis; appendicitis; pneumonia; osteomyelitis; cellulitis; bacterial gastroenteritis; complicated urinary tract infection.

Outcomes

This seems like a sensible primary outcome. It is worth considering the impact of including cellulitis in this group. We know that these children do have a high CRP, and their diagnosis should be obvious on initial assessment. Including them has the potential to positively skew the results (although there were only 3 children in this category out of 272).

 

Analysis of results

The authors analysis looked at three key areas:

  1. Baseline characteristics. Median age was 1.5 years; 53.5% were boys. The overall prevalence of SI was 4.9% (272 patients), and was higher in ED than in the urgent care clinic. Pneumonia and complicated UTIs were the most common SI. No children died.
  2. Accuracy of individual features. This looked at the 61 features. There was a low overall sensitivity (<65%) meaning that there will be large number of patients who do not have these features that do have SI. A number of features did raise the probability of infection however:- clinical impression that the child is seriously ill; moaning; bloody diarrhoea; abnormal behaviour; abnormal fontanelle tension; reduced peripheral circulation; meningeal irritation; cyanosis; and peritoneal irritation.
  3. Algorithm. The authors constructed their algorithm using a Classification and Regression Tree (CART) – this used PoC CRP and 18 of the clinical features (depending on the CRP result). This is clearly explained in their flow chart. Any one positive clinical feature or vital signs classifies the child as high risk.

 

The algorithm classified 36.4% of the population as low risk. 8 children with SI were misclassified as low risk (CRPs from <5 to 31mg/L).

Analysis

The data is adequately described and the numbers all add up consistently. The results are presented clearly allowing the reader to make their own judgement. The data are suitable for analysis and the methods used are appropriate.

 

Discussion

The results are discussed with the authors first considering the validity of CRP on its own. They establish that low CRP levels alone cannot rule out SI, Approximately one third of patients with SI had CRP >75 (37%); one third had CRP 20-75 (32%); and one third had CRP <20 (31%). Using CRP<20 to rule out SI would have missed six cases of SI.

The authors suggest using CRP in the algorithm was more successful (although this misclassified eight patients with SI as low risk). The suggest for use of this tool is as a triage tool – where children with a CRP>75 should be assessed by a senior clinician, whereas the others can be assessed by  a junior doctor.

 

Will I change my practice? 

In my early years as a paediatric trainee, I used to use CRP and FBC to reassure myself about ruling out SBI – similarly if the result was high then I would be more worried. As my understanding of the statistical relevance of these tests has improved, along with my experience and clinical skills, I no longer use this as a test to inform my suspicion of SBI.

Even if there was a clear cut-off known to advise us when a CRP is ‘too high’, in a population where we have such a low prevalence of disease, a positive result is difficult to interpret anyway.

In this paper we see that when using >80mg/L as a cutoff, the specificity is 95%. In a population of 100 unwell children therefore, five would have a positive result even though they had no SBI. Also in this population of 100 febrile children, with a prevalence of 5% of SI, five children will have an SI. Best case scenario is that all five children with an SI have a positive CRP (>80mg/L) – although we know that in reality they won’t.

So best case scenario in this population is that we have 10 patients with a CRP >80mg/kg and only five of them have SI. We are left with a 50:50 chance. And conversely with a low pre-test probability, a negative test doesn’t really add anything either.

Overall, I’m not clear what a CRP adds in addition to our regular clinical assessment, and the NICE traffic light system. Consequently the authors have had to conclude with an algorithm that is used only as a triage tool to decide which type of doctor assesses the child. This algorithm may be useful in some units if it is validated more broadly, but the title gives a misleading statement about what CRP can contribute to the diagnostic conversation.

 

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Scarlet fever

The start of 2018 has seen UK hospitals receiving an alert from Public Health England about the rise in cases of suspected scarlet fever. What is the extent of the problem and how good are we at actually diagnosing scarlet fever?

As of a few weeks ago, Public Health England had received 11981 notifications of scarlet fever in the winter season. The average number in the previous five years has been 4480. 89% of these notifications were for children under 10 years of age and the median age was 4 years. The infection rate is highest in the 1-4 year old age group.

 

What is scarlet fever?

Scarlet fever is an infection caused by Group A Strep (Strep pyogenes). Group A strep can colonise the throat or the skin, and we know that up to 20% of (healthy) children are already colonised. When the Group A strep causes infection, the bacteria releases an exotoxin which causes the rash and the fever. The primary site of infection is usually the throat.

It is very contagious and is easily spread through saliva or mucus i.e. on toys at pre-school. It can also be transmitted through respiratory droplets. The incubation period is 2-5 days.

 

What are the symptoms?

The symptoms usually start with fever (over 38.3oC), sore throat, and general fatigue/headache/nausea. 12-48 hours later a rash appears on the abdomen and then spreads to the neck and extremities.

Characteristic features of the rash are:

  • Rough texture (like sandpaper)
  • Worse in the skin folds e.g. groin, axilla, neck folds (Pastia’s lines)

 

Other symptoms include: white coating on the tongue which then peels and leave a ‘strawberry’ tongue; flushed red face but with peri-oral pallor; cervical lymphadenopathy

Most symptoms resolve in a week. After the symptoms have resolved, it is common to get peeling skin on the fingertips.

https://commons.wikimedia.org/wiki/File:Scharlach.jpg

You usually only get Scarlet Fever once in your life.

 

How is diagnosis confirmed?

Diagnosis is clinical.

A throat swab is not routinely recommended, although during specific outbreaks Public Health England might advice this.

If you aren’t going to treat the patient but you think they do have Scarlet Fever (see the discussion below about the utility of antibiotics) then you should consider sending a throat swab. Otherwise they will need to be excluded from school for two weeks.

 

What is the treatment?

Most mild cases will clear on their own (with no treatment).

There are two reasons for treating scarlet fever with antibiotics – prevention of complications, and prevention of transmission.

 

1. Prevent complications

Complications of Scarlet Fever are much the same as complications of strep tonsillitis. They are divided into suppurative, and non-suppurative.

Suppurative complications occur due to the infection spreading, and include: otitis media; mastoiditis; sinusitis; peritonsillar abscess; meningitis; endocarditis; retropharygneal abscess; and invasive group A strep (IGAS).

Non-suppurative complications occur later and occur mainly in untreated patients. They are rheumatic fever and post-strep glomerulonephritis.

IGAS is not common in children, but those at increased risk are children with co-morbities, immunocompromised children, and those with co-existing chicken pox.

 

RebelEM makes a great case for why treating strep throat with antibiotics is not helpful, and the same principles should apply to Scarlet Fever.

If you’re treating for symptom relief – treating with antibiotics provides about 6-12 hours improvement in the length of symptoms when compared with placebo. This doesn’t take into account treating with fluids, and analgesia, or even giving a one off dose of steroid (to be carefully considered in kids).

If you’re treating to prevent suppurative complications – a large study (14610 patients) in adults showed that the rate of suppurative complications are 1% regardless of whether or not antibiotics were given.

If you’re treating to prevent non-suppurative complications (rheumatic fever or post-strep glomerulonephritis) – the incidence of rheumatic fever is so low (and, before you say it, the reduction in rheumatic fever, or strep, predated the introduction of antibiotics and is related more to sanitation) that we would have treat millions of strep patients to prevent one case of rheymatic fever.

 

2. Prevent transmission

Public Health England have noted an increase in notifications for IGAS this winter season too – 1162 notifications compared to an average of 669 from the previous five years. However the IGAS risk is much higher in the older population (media age is 55 years old). There has not been a significant increase in IGAS notification in children under 10 years of age this year compared to previous years. One rationale for the Public Health England recommendations are to prevent transmission of Group A strep from children to vulnerable adults.

If you do decide to treat, then treatment is with 10 days of penicillin. Amoxicillin can be used if there is a concern about compliance. Use azithromycin in penicillin allergy.

The fever usually settles 24 hours after starting the antibiotics but the treatment course should still be completed.

 

What is the exclusion period?

Children should be excluded from school until they have had 24 hours of antibiotics. (see our list of exclusion periods for other illnesses here). If you decide not to treat though, the exclusion period is two weeks (so you may wish to consider a throat swab for diagnostic help).

Of course, Scarlet Fever is a notifiable disease – so don’t forget to let Public Health England know.

 

 

References

Scarlet fever: FAQs, Public Health England

Group A Strep infections: seasonal activity 2017/2018: second report, Public Health England

Scarlet fever, NICE CKS

Group A Strep disease for clinicians, CDC

 

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